Complaint·July 12, 2023

S1 reported when they were transferring R1 to the shower bench, R1 lost their balance and S1 assisted the resident down to the floor. R1 sustained a skin tear and paramedics were called. The internal report was completed by Staff #2 (S2). Ms. Hoznor stated R1 is a two person assist and a fall risk, but they have not had any falls since Hoznor has worked at the facility. The 08/22/2021, service plan for R1 revealed R1 is a two-person assist with transfers. During the visit, the LPA was advised that S1 was an agency staff and not a permanent employee of the facility. Both S1 and S2 were not available for interview during this visit. On 03/22/2022 at 6:46 p.m., CCLD received an Unusual Incident/Injury Report (LIC624) regarding the 03/18/2022 incident with R1. On 07/07/2023, the LPA conducted a subsequent inspection at the facility and conducted an interview with S2, R1, and the family member of R1 between 11:55 a.m. and 1:55 p.m. The LPA attempted to obtain contact information for S1, but it was not available. Interviews with R1 and their family member revealed that R1 did not recall the incident but R1’s family member did recall the incident. The family member stated they met R1 at the hospital when the incident occurred and although, a laceration to the labia was in an odd place for a fall, the family member did not suspect any type of abuse occurred by any staff members at the facility. The family member also stated at the time of the incident, R1 never suggested any type of abuse occurred. Interviews revealed S2 was not present when the fall occurred but arrived afterwards due to the resident being injured. S1 reported to S2 that the injury occurred when the resident slid off the shower bench. S1 was the only staff member present when the injury occurred. It has been determined there is insufficient evidence to support the allegation of physical abuse to resident while in care occurred. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview and report reviewed with the interim Administrator. Deficiencies observed during the investigation will be addressed under a separate report.