Complaint·September 17, 2021

Staff physically abused resident: Between 10/05/2020 and 10/08/2020, the Department interviewed residents R1 and R2. R1 was not able to provide information of how R1 sustained injury due to poor memory while R2 (R1’s roommate) stated the facility staff did not hurt R1. R2 stated R2 heard R1 fell down. Based on review of R1’s facility file and the facility emails to R1’s family member showed that facility staff notified R1’s family member regarding R1’s skin discoloration on R1's body and changes on medical condition. R1’s doctor has been informed of R1’s medical condition. On 8/26/2020, R1 was examined by R1’s doctor who started a supplementation and the resumption of Calcium given for R1’s history of fragility fractures. On 09/06/2020, the facility reported to R1’s doctor that R1 had a purplish discoloration on R1’s left knee and lateral thigh with no swelling or pain. Based on R1’s medical review, R1 has left side deficits, and is wheelchair dependent. R1 has episodes of confusion, combative behavior and refusal of care when upset. There was no evidence of abuse from R1’s medical exam. On 09/16/2020, the department interviewed Staff (S1) who stated that R1 was experiencing pain and reported to facility nurse. Facility nurse assessed R1 who was not able to verbalize the location of R1’s pain. On the same day at approximately 11:00 hours R1 complained of knee pain. R1 was assessed wherein R1’s knee was swollen and warm but not discolored. Facility informed R1 doctor and scheduled a video Tele Visit. R1 was prescribed pain reliever and topical cream and icing. R1 was monitored by staff but did not show any improvement. R1 was transported to the hospital on 09/17/2020. On 9/18/2020, facility filed an Unusual Incident Report to Department regarding R1's swelling of the knee. None of the facility staff interviewed during the investigation could explain the cause of R1’s injuries. Continued, see LIC 9099-C, page 3 of 3. On 10/01/2020, the department interviewed a staff (S1). S1 stated S1 could not tell how R1’s injury occurred or how long R1’s leg had been injured. The department interviewed 8 caregivers (S1 - S8), and all of them denied abusing R1 or having knowledge of other staff abusing R1 On 10/12/2020, the Department interviewed R1’s Orthopedic doctor (OD) about R1’s fracture. OD stated that R1 has a low bone density which makes it easier for a person to fracture a bone easier than who has a normal energy. The Department has investigated the above allegation. Based on interviews conducted and records reviewed, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies or citations issued at today’s complaint investigation visit. Exit interview conducted with Administrator (ADM). A copy of this report was provided for signature. A copy of this report was emailed to ADM.