complaint·September 26, 2023

Continue from LIC9099) Facility staff immediately called 911 and R1 was taken to the hospital, then discharged the same day with a diagnosis of a sprained wrist. During a visit to the facility conducted on August 23, 2023, R1’s wrist was observed with no signs of injury and R1 was able to move their wrist with full range of motion with no pain. Statements obtained during multiple interviews with R1 regarding the alleged incident were inconsistent due to their dementia. A detailed review of R1’s medical records, service care plan, and daily charting notes indicated that due to documented medical conditions, R1 would often get agitated and would act aggressively toward staff. During a visit to the facility conducted on August 31, 2023, R1 was observed during one aggressive episode which caused a self-inflicted minor injury to R1’s foot. Facility staff were able to de-escalate the situation successfully and R1 immediately calmed down. In addition, staff applied first aid care to R1’s foot. A review of facility records disclosed other reported aggressive incidents involving R1 that although R1 was not injured, resulted in minor injuries to a staff member. S1 and care staff denied the allegation and maintained during interviews they did not know the source of R1’s injury to their wrist. A review of R1’s daily charting notes during the month of August 2023 indicated two other incidents when R1 did not use the call button and staff would find R1 trying to get out of bed using the bed rail as support. Staff communicated the incidents to R1’s medical provider who subsequently made changes to R1’s medications to minimize anxiety and aggressive behavior. Multiple interviews with residents and staff indicated no concerns with S1 mishandling or mistreating residents. Based on observations, record reviews, and interviews with staff and outside sources there was insufficient evidence to support the allegation that S1 mishandled R1. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Business Office Manager, Rebecca Toves, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) was provided at the conclusion of the visit.