complaint·August 12, 2024

Report Continued from LIC 9099... It was alleged that staff are inappropriately restraining resident in care. It was reported that Resident #1 (R1) was sitting in a wheelchair while being restrained by two (2) different devices. One (1) device being a bath robe that was tied around the wheelchair and shoelaces tied together around R1’s waistband and secured to the back of the wheelchair. Records reviewed revealed that R1 was admitted to the facility on 06/12/2024. Per Physician’s Report, dated 06/07/2024, it lists R1’s primary diagnosis of dementia and temporal lobe lacunar infarct and secondary diagnosis of anxiety, mood disorder, and a high fall risk. Additionally, it states under R1’s mental condition that R1 is confused/disoriented; however, is able to follow simple instructions and is able to communicate their needs. Interviews conducted with staff revealed that R1 was constantly being supervised as R1 had one (1) caregiver specifically watching over them at all times. During staff interviews, staff denied restraining R1 or any other resident while at the facility. Interviews conducted with residents revealed that facility staff is nice and reported having no concerns living at the facility. Furthermore, three (3) out of three (3) residents interviewed denied being restrained by facility or witnessed staff restraining another resident at any time while living at the facility. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “staff are inappropriately restraining resident in care", is deemed Unsubstantiated at this time. It was also alleged that resident sustained an unexplained injury while in care. It was reported that R1 had a large bruise on the right cheek which extended upwards toward the temple. Record review of incident report dated 06/13/2024, stated that R1 was agitated at night and was banging their head on the wall while yelling and screaming. The caregiver sat beside R1 for the rest of the night; however, the caregiver reported that R1 had sustained a bruise on their forehead as a result from R1 banging their head on the wall. Records reviewed and interviews conducted with staff revealed that after the self-injury incident with R1, R1 was placed on bleeding / bruising precautions due to R1 being on blood thinner. Additionally, staff stated that R1 was placed on constant supervision. The Administrator stated that they had hired a caregiver specifically to supervise R1 at all times to avoid R1 from harming themselves. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Furthermore, during resident interviews, residents stated that staff are nice, they feel safe living at the facility, and reported no concerns. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “resident sustained an unexplained injury while in care ", is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.