Complaint·September 15, 2022

Report Continued from LIC 9099: documents. The following was then determined: It was alleged that Resident (Resident #1 – R1) was physically abused while in care. Record review revealed that on 12/10/2020, during weekly skin monitoring, there was an open area noted on right hip with discoloration. Affected area was cleansed, dried and treated by the facility nurse. An incident report was sent to the Regional Office which was dated 12/11/2020 indicating R1 was noted with discoloration to lower abdominal area during toileting. Resident denied pain or discomfort to affected area. R1’s family member requested R1 be transferred to the hospital for evaluation. Care notes reveal that medical evaluation and rape test conducted at the hospital indicated “no evidence of injury was found.” R1 moved out of the facility upon discharge from the hospital, so R1’s hospital records were not provided to the facility. Record review revealed that R1 had diagnoses which included dementia, gait instability, and R1 is at risk for falls. R1 required transfer assistance, escorts, and assistance with all hygiene needs. Additionally, physician’s report did indicate R1 is able to independently transfer to and from bed and R1 used a wheelchair to ambulate. Interview revealed that any abnormalities in a resident’s appearance would be reported to the medication technician and the floor nurse or med tech would assess the resident. After initial assessment, care notes would be written, and any incident would be reported to the resident’s family and primary care physician. In the case of R1, care notes did reveal observed discoloration, but no known cause was noted. According to the report, R1 denied pain or discomfort at the time of the observation and R1’s physician’s report indicated R1 is able to communicate needs. Around the time of the allegation, there is no report indicating R1 told staff that they were injured or in pain. Based on record review and interview, although the allegation may be valid, at this time there is insufficient evidence to prove a violation occurred, therefore the allegation that “Resident was physically abused while in care” is deemed UNSUBSTANTIATED at this time. No deficiencies were cited. Exit interview conducted with Jennifer Miller, Business Office Manager. A copy of the report was provided to the Administrator via email.