complaint·September 26, 2024

LIC 9099-C Allegation: Resident sustained unexplained bruising. Based on file review conducted, incident report submitted to Community Care Licensing revealed that R1 was transported to the emergency room for evaluation on March 30, 2024 then after five days on April 4, 2024, R1 was transported to a skilled nursing facility. Based on file review conducted R1 was discharged from skilled nursing and returned to the facility on April 22, 2024. Based on shower skin sheet for R1, it revealed on April 23, 2024 R1 was documented to have scratch marks on R1's right lower thigh and foot. Additionally, it was documented of discoloration/bruising on R1's left arm. The following was observed and documented by Assistant Administrator. Based on resident care notes reviewed, it was revealed on May 1, 2024 facility faxed R1's primary care physician for advisory regarding "old discoloration and spreading and color changed". On May 3, 2024, it revealed "resident's discoloration is getting better and fading. Will continue to monitor and report changes." Based on R1's Mini-Mental State Examination conducted on April 23, 2024, it revealed there was a list of eleven (11) questions with the maximum score of 30, R1's score was zero (0) with a second try refusal. Based on R1's preplacement appraisal on April 20, 2024, it was documented that R1's mental condition was listed as "confused and disoriented with hallucinations sometimes". Based on interview conducted with Administrator, it revealed that R1 has dementia and is often forgetful where R1 informed Administrator and Long Term Care Ombudsman that R1 does not know what happened. Interview with R1 revealed that R1 does not recall living at the facility, but R1 does remember having a big bruising. R1 was unable to state if R1 was injured at skilled nursing facility prior to returning to the facility or at the facility. With the information obtained, LPA found the allegation to be unsubstantiated as R1 is unable to recall the incident along with facility having skin check documentation of bruising present when R1 returned to he facility after skilled nursing discharge. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of the report was provided.