complaint·October 29, 2024

Multiple staff interviewed stated they have observed S1 slamming cupboards, which was disruptive to residents. Staff also stated S1 has argued with them in front of clients, after refusing to help with tasks that would assist clients, such as retrieving yogurt for a resident that had a cough. One Agency staff, a Certified Nursing Assistant (CNA), interviewed stated they had not witnessed either incident, and had not seen or heard S1 yell, hit or scream at a resident, but had heard of things happening from other staff. Multiple staff stated S1 gets rude and defensive when other staff intervene and inform S1 their behavior is inappropriate. Multiple staff stated they informed the supervisor after witnessing the incidents and inappropriate behavior from S1. Staff asked the manager if S1 could cover different clients in the facility that are more independent than the ones S1 was currently assisting, and this was enacted. Staff stated R1 and R2 get very agitated when S1 is on shift following the incidents. On the allegation: Resident fell due to staff not assisting resident appropriately. It was alleged when assisting Resident 2 (R2) at the dining table, S1 did not properly assist R2 and allowed R2 to fall, when the fall could have been prevented. One staff stated they were a witness to the fall incident on 12/26/2023 with S1 and R2. R2 uses a walker, and staff interviewed stated they need to make sure the chair is stable before R2 sits down. S1 was in charge of care for R2 and was getting R2 to the dining table. R2 typically sits in a chair at the dining table, but on this occasion, S1 had R2 stand up holding onto the table and repositioned R2’s walker backwards to sit on. R2 lost their balance and started to stumble, and other staff present believed S1 could have prevented the fall from occurring by assisting R2 to slide down instead of fall, but S1 backed away and instead let R2 fall. Another agency staff, a Certified Nursing Assistant (CNA), on duty went over to assist, and S1 tried to sit R2 on the walker again. The CNA instructed S1 to get a real chair for R2. Another staff went to assess R2 after the fall to ensure they were walking ok. R2 was not hurt in this incident. Staff stated after this incident, S1 does not work with R2 due to being “neglectful in [their] duties.” The Administrator at the time confirmed these two separate incidents with S1 occurred, on different days. The shower incident occurred around 12/10/2023-12/15/2023 and the fall incident with R1 occurred on 12/26/23. There is camera footage of the chair incident but not the bathroom incident. Administrator stated at first they thought there was not enough evidence to prove the bathroom incident occurred, until another staff stated they witnessed the incident. Then they reported the incident to Corporate. Administrator stated they counseled S1 on 12/28/2023 about their behavior. Supervisor stated S1 was not being left alone with residents and other staff were present supervising after the incident. Administrator and supervisor stated S1 was a new staff and had been written up multiple times. The first write-up was on 12/15/2023 for yelling at R2 in the shower and arguing with another staff loudly in the presence of residents. S1 also received a write-up for the chair incident. Based on the information obtained, both allegations are deemed Substantiated at this time. Exit interview, deficiencies cited on 9099-D, report given, appeal rights given.