complaint·October 12, 2021

On 6/8/2021, 6 staff were interviewed. LPA was unable to interview the third staff on duty as the staff did not return LPA’s calls. 6 out of 6 staff denied there was a lack of supervision in facility and that staff responded to this incident within a minute. Staff stated they had 3 staff and a med-tech on duty for AM & PM shift and 2 staff and 1 med tech for the NOC shift. Residents were checked every 2 hours but has since increased monitoring to every hour for R2 who has sundowning. Based on interview with the staff (S1) who was on duty during the incident, S1 was at the scene within 1 minute and observed R1 on the floor with minor bump on forehead. The police report reviewed noted that the staff (S2) who also was on duty during the incident responded to the incident right after the altercation took place. R1 was interviewed by the police and disclosed that a male staff came into R1’s room but R1 told him to leave. The male staff got angry and pushed R1 down. Per the police report, R2, the suspect, a resident, was also being interviewed by the police but was unable to provide any accurate information due to dementia. The police report also stated that this case was determined to be inactive as both residents (R1 & R2) involved in this incident are diagnosed with dementia. Staff schedule record review confirmed 3 staff and 1 med-tech on duty for AM & PM shift on day of incident. This Department has investigated the above allegation. Based on interviews and record review, the Department found that the above allegation is UNSUBSTANTIATED. Unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. This report was reviewed the Executive Director . A copy of this report was provided.