Complaint·November 4, 2024

LPA Moleski received an incident report regarding R1’s injury on 8/12/24. The incident report stated that Enriquez was notified by a caregiver on 7/19/24 that R1 was complaining of right arm pain. R1 was taken to a hospital for treatment on that same date, according to the incident report. In an interview, Enriquez said that R1 did not fall, and did not suffer any other unusual injuries leading up to the discovery of the injury. She said her caregivers were made aware of the injury as described in the incident report when R1 started crying out when moving their arm in the shower. Enriquez said that R1 suffers from severe aphasia and is unable to articulate themselves well. However, she said that she asked the resident if they fell, to which they responded in the negative. LPA Moleski interviewed R1 at a skilled nursing facility. R1 was not able to speak clearly or elaborate upon their answers. However, when asked, R1 indicated that they had not fallen, and had not been abused or otherwise injured by staff while residing at this facility. When asked, R1 indicated that they did not know how they suffered the fracture. In interviews with all other residents of this facility (R2-R5), none indicated that they had observed any falls suffered by R1, and none had any pertinent information to share regarding the cause of R1’s injury. In interviews, no staff members (S1-S5) were able to provide pertinent information regarding the cause or circumstances surrounding R1’s injury. None of the staff interviewed had witnessed any falls immediately prior to the discovery of R1’s injury, and none of them had observed any physical abuse being perpetrated by other staff members. S1 said that R1 had never fallen, but said that they had observed R1 sleeping on their arm, potentially causing strain. S1 said they discovered the injury when R1 started repeating the word “hurt” while showering. S1 said that the administrator was called and R1 was sent to the hospital afterward. In an interview, R1’s home health nurse said that they suspected some sort of physical trauma had occurred in order to cause the injury, but had not observed any physical abuse being perpetrated by staff of this facility, and was not aware of any falls suffered by R1 while living at this facility. [continued 9099-C] In an interview, R1’s case manager said that medical documentation on file showed that R1’s injury was initially classified as pathological, but it was later determined by medical personnel that the injury was suspicious. The department has determined the following as it relates to the allegation that a resident suffered a fracture due to staff neglect: Based on interviews and record review, the above allegation is UNSUBSTANTIATED, which 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. No deficiencies were cited regarding this allegation. An exit interview was held and a copy of this report was left with Enriquez.