complaint·February 15, 2023

Regarding the allegation: Staff caused injury to resident in care It was alleged that a staff injured Resident #1’s (R1) right arm, causing injury. Interviews and record review confirmed that on 07/06/2022, R1 disclosed to staff that Staff #1 (S1) had pulled their arm and choked them, and R1 was complaining of shoulder pain. Staff interviews revealed that on 07/06/2022, S1 approached R1 in their room, and S1 noted that R1 was agitated. R1 needed to be showered, and staff indicated that they had assisted R1 with removing their clothing, in which R1 responded by striking S1 on their shoulder. S1 was able to get R1 in the shower, but R1 began screaming and S1 claimed R1 was ‘combative’ in the shower. S1 was the only staff assisting R1 at that time. S1 claimed that R1 was combative and as a result, S1’s arms were scratched in the process. In the interview conducted with S1 on 07/14/2022, S1 admitted that they pressed their shoulder and body against R1 while showering R1, to prevent R1 from further hitting and scratching them. S1 denied handling R1 roughly and denied claims that they pulled R1’s arms or choked them. On 07/06/2022, R1 disclosed to other staff that R1’s shoulder hurt and claimed that S1 had hurt them. Witnesses indicated that R1’s shoulder appeared red. R1 was given pain medication and the incident was reported to management. R1 exclaimed that they were still in pain, and on 07/07/2022, R1 was sent to urgent care for an x-ray. The x-ray ruled out any fracture or dislocation of R1’s right shoulder, and R1 was diagnosed with shoulder pain and prescribed pain medication. Staff said that the incident was reported to R1’s responsible party and the local police department. The police interviewed S1, and it was determined that the police could not identify any criminal intent. Staff denied claims that they had ever observed S1 harm R1 or any other resident in the facility. Staff interviews supported claims that R1 would exhibit agitation while receiving assistance with toileting or showering if R1 was experiencing pain, or if staff do not fully explain how they are assisting R1 with care prior to assisting R1. Staff interviews revealed that they had experienced times in which R1 had hit them as a result of agitation. Staff also indicated that as a result of the incident that took place on 07/06/2022, R1 is now a two-person assist for showers as a result of R1’s risk of agitation. In response to resident agitation, staff claimed that they are trained to either ask for assistance with care, ask another caregiver to switch with them as a different caregiver may be able to gain compliance, or give the resident space to calm down and return at a later time to assist with care. Based off the information obtained from interviews and record review, there is insufficient information to support the claim that S1 caused injury to R1. S1 and staff reported that R1 would sometimes hit staff due to agitation. During the incident on 07/06/2022, R1 and S1 were the only two people present during the incident and there were no other witnesses. Staff claimed that they observed S1’s arms after the incident and observed scratch marks. As R1 was allegedly becoming aggressive towards S1, it is unclear whether R1 hurt themselves in the process. S1 denied claims that they pulled R1’s arm, choked R1 or intentionally harmed R1. Based on the investigation, there is insufficient evidence to support the claim that S1 caused injury to R1. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. However, the deficiencies lie in the staff’s failure to properly assist R1. S1 admitted to pressing their shoulder and body against R1 while showering. S1’s behavior of holding R1 with their body in an attempt to restrict their movement is a personal rights violation. S1 could have attempted different interventions to assist R1 by way of practicing non-physical intervention methods. A Case Management report will address this deficiency. Regarding the allegation: Staff yells at residents in care It was alleged that certain staff yell at the residents when the residents ask questions. Inconsistent statements were provided regarding this claim; however, in general, information obtained did not support claims that staff are observed yelling at the residents. Staff claim that they may appear stern with some of the residents but said they have not observed persons raising their voice or yelling at a resident with malicious intent. Resident interviews further denied claims that they had been yelled at by the staff in the facility. Based on the investigation, there is insufficient evidence to support the claim that staff yell at residents in care. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report issued. A Case Management report will be issued to address the personal rights violation.