complaint·November 21, 2022

When staff asked R1 what happened, R1 stated “that animal” hit R1. S1 cleaned up the blood, assisted R1 back to their room, and observed R1’s walker in the room. S1 conducted their rounds on residents and observed that R2 was awake. S1 checked R2 for any injuries and did not find any injuries on R2 that may be indicative of R2 hitting R1. S1 called the facility’s Executive Director to notify her of the incident with R1. S1 stated that they did not notify R1’s responsible party of the incident due to not having a fluent Spanish speaking staff on duty at the time. S1 stated that S1 did not call for an ambulance because R1’s injury did not show any signs of needing to go to the hospital. Staff stated R1 and R2 slept for the rest of the night without further incidents. At around 7:15am on October 30, 2021, staff 2 (S2) started their shift and observed R1 moving slowly, had dried blood on R1’s nose, and R1 was complaining of pain. When S2 asked R1 what happened, R1 stated a resident punched R1 in the face, causing R1 to fall on the floor and then that resident started kicking R1. R1 stated that they did not tell anyone about the attack at that time. At 8:00am, S2 observed R1 looking pale and asked R1 who hit them and R1 pointed to R2. Interviews revealed that staff called R1’s granddaughter in the morning of October 30, 2021 to explain the incident between R1 and R2 and requesting to transfer R1 to the hospital because R1 was complaining of pain. R1’s granddaughter placed the phone call on speaker phone so staff could also speak to R1’s son. R1’s son spoke to R1 and agreed to have R1 sent to the hospital for evaluation. After R1’s condition did not improve after breakfast, staff called an ambulance for R1 at 9:00am. Review of R1’s hospital medical records revealed that R1 had two pre-existing rib fractures and did not have any bruising noted on R1’s back or abdomen. Interviews with R1’s family revealed that on October 30, 2021, hospital staff informed them that they were unable to determine when the fractures occurred and that there was no bruising to indicate the fractures occurred recently. R1’s family stated that R1 had fallen at the facility in the past and bruised easily. R1’s family checked R1’s body and did not observe any bruises so they did not think that R1 had been in a fight. Continued on LIC9099-C page... Interviews with staff and review of R2’s progress notes revealed that R2 had a history of trying to assist other residents like a staff member and had started guarding the bathroom by standing in front of it and pacing. R2’s progress notes revealed that R2 did not have aggressive behaviors upon move in and became aggressive around August 2021. On August 3, 2021, R2 was admitted to the hospital for evaluation after being observed raising a hand to strike another resident. R2 returned to the facility on August 17, 2021. On September 3, 2021, R2 began taking medication for aggressive behaviors and was being monitored by staff. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Wellness Coordinator Jenna Purnell , to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.