complaint·September 16, 2024

The complaint alleges that Staff #1 (S1) was rough with Resident #1 (R1) and that S1 hit R1 with an unknown object while putting R1 to bed. LPA interviewed staff and R1, as well as R1’s family member related to the allegation and reviewed facility documents. Staff interview revealed that on the date of the alleged incident, R1 was having a rough night. R1 was agitated and was hitting the facility staff, including S1. R1 also reported to the police on the night of the incident that R1 had hit S1 in the stomach. R1 showed the police an injury which was reportedly caused by S1 that night, however police noted the injury “appeared to be a scab that was scraped off from a pre-existing injury.” Resident observations indicate that R1 had a fall on 04/16/2024, which resulted in a skin tear to R1’s left leg and small scrape to R1's right leg. Staff notes continue to mention the skin tear somewhat regularly and on 05/24/2024, the skin tear is referred to as “old skin tear” on R1’s right leg. The alleged incident occurred on 06/02/2024 and police noted the injury appeared to be an old picked off scab. LPA observed R1’s left leg during the initial visit and took photographs of the injury, which was scabbed over at that time. Physician’s report reviewed indicates R1 has a diagnosis of Mild Cognitive Impairment. LPA interviewed R1, who initially told LPA that an injury to their leg was caused while R1 was on a boat when the mast hit them in the leg. Later in the interview, R1 indicated the injury was caused by S1 hitting them with a stick, resulting in a cracked kneecap. The injury was noted to be on R1’s left lower leg, not R1’s kneecap. LPA interviewed R1’s family member related to the incident, who stated they were unsure if “it’s happened, imagined, or if [R1] dreamed it.” Staff and R1’s family member stated that R1 has been experiencing confusion and sundowning recently. LPA requested a copy of a police report from the night of the incident, however, the police did not make a written report. Based on interview and record review, although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that a violation occurred, therefore, the allegations “Staff handled resident in a rough manner” and “Staff hit resident with unknown object” are deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.