Complaint·December 4, 2024

It was alleged that on September 18, 2022, R1 had a fall at the facility, sustained bruising to the left thigh and a large hematoma on their back, and that R1 stated that a staff at the facility had pushed them. When interviewed, R1 reported that Staff #1 (S1) was the one who pushed them and S1 pushes them every day. When interviewed, S1 reported that R1 had accused them multiple times of pushing them, but S1 denied ever having pushed R1. Per S1, R1 is confused and unstable on their feet due to having Huntington’s Disease, R1 falls frequently, when S1 tries to catch R1 during falls or otherwise assist them during falls R1 would accuse S1 of pushing them, and that on September 18, 2022, S1 was not present in the room when R1 fell. Interviews with AD and one staff corroborated S1’s statements. Another staff reported that they were in R1’s room when they fell on September 18, 2022, and that R1 was standing by their bed while the staff was picking up R1’s dinner plate, R1 fell backwards landing on a small laundry basket and breaking it, the staff called S1 from another room to assist before 911 was called, R1 did not accuse S1 of pushing them at that time, and they have never seen S1 push R1. Attempts to interview R1’s responsible party were unsuccessful. A facility Incident Report dated September 19, 2022, states that R1 fell on September 18, 2022, because they suddenly stood up and lost their balance after eating dinner. The facility’s Progress Notes for R1 document instances of R1 having falls, R1 accusing staff of pushing them, staff denying pushing R1 and stating that R1 fell by themselves, staff reminding R1 to use their walker, and staff requesting that R1 not make accusations that they are being pushed by staff. Per R1’s Physician’s Report dated July 10, 2022, R1 has Huntington’s Disease with severe Choreiform movements and R1 is non-ambulatory. R1’s Preplacement Appraisal dated July 19, 2022, indicates R1 has balance issues and forgets to use their walker. Per AD, R1 had communicated that they did not want to live at the facility and AD believes R1 would fall on purpose when they did not get what they wanted. Per the facility’s Progress Notes for R1, R1 was taken to the hospital on October 2, 2022, for an unrelated reason and did not return to the facility as they needed a higher level of care. S1 and another staff stated that sometimes when R1 was falling, staff would catch R1 to prevent the fall. Per S1, whenever S1 would catch R1 during a fall and lift R1 back up, R1 would accuse S1 of pushing them, and R1 may have been perceiving S1’s assistance as S1 pushing them. R1 also made a statement that S1 threatened them once on September 18, 2022. Interviews with AD, S1, and other staff did not disclose any information regarding this alleged incident and the facility’s Progress Notes for R1 do not document that S1 threatened R1 or that R1 ever accused S1 of threatening them. R1’s Medical Records dated September 18, 2022, indicate that R1 did not report being threatened by S1 to hospital staff while they were hospitalized for three days, although R1 did report that S1 had pushed them. The current residents and staff of the facility were not present at the facility on September 18, 2022, and R1 did not have a roommate. LPA interviewed AD and all current residents and staff and did not obtain information corroborating that staff are threatening residents. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegation that a staff member pushed resident resulting in a fall and injuries occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.