Complaint·November 18, 2024

It was alleged that physical abuse by staff led resident to sustain a large bruise. Interviews with Licensee, Administrator, Staff #1 (S1), and Staff #2 (S2) agreed that on 10/08/2024, Resident #1 (R1) asked S1 to leave their wheelchair by the bed before S1 left R1’s room, but S1 did not feel it would be safe since it would prompt R1 to attempt to transfer from the bed alone and risk a fall. R1 got agitated and swung the phone pull cord at S1, which then led to S1 grabbing R1’s hand to remove the pull cord. S2 stated they were nearby and heard R1 yelling “stop hitting me.” S2 stated they immediately went to R1’s room and observed R1 holding the pull cord and S1 trying to remove the pull cord before R1 could hurt S1. S2 stated that S1 was not hitting R1, but R1 claimed that S1 slapped their hand. S1 denied the claim and told S2 they were trying to remove the pull cord. S2 stated they told S1 to leave the wheelchair by R1’s bed and to leave the room so R1 could calm down. S2 stated they did not observe marks on R1 or S1 and that there have been no other incidents with R1. The complainant alleged that a large bruise was observed on R1’s right arm that was different colors, indicating the bruise could be older. The complainant stated that R1 has a condition which gives R1 an unsteady gait and has caused multiple falls, and that it is possible the bruise is from a previous fall. However, the complainant stated that R1 stated multiple times that facility staff hit R1. According to the complainant, R1 did not initially state that S1 hit R1 and R1 denies every hitting S1. LPA interviewed R1 who stated that they “feel safe” but there was an incident two weeks ago where staff “punched” R1. R1 stated they do not remember the staff member, what they look like, or what events led up to the incident. R1 was unable to provide additional details to LPA. R1 stated they were told that the staff member would be kept away from them. The complainant, S1, Licensee, Administrator, and S2 also confirmed that S1 will not tend to the resident and is covering a different section of the facility. The complainant, R1, Licensee, and Administrator, all confirmed that R1 stated they do not want S1 to lose their job. Report Continued on LIC 9099-C The Licensee conducted an investigation and had undetermined findings due to S1 and R1 having different accounts of the incident. Family of R1 stated they felt the incident was handled in a satisfactory way. Record review of R1’s medical records indicate that R1 is prescribed a daily 81 mg dose of Aspirin, a blood thinner medication that could cause easy bruising. A physician’s report dated 08/06/2024 and appraisals dated 08/08/2024 indicate that R1 has an abnormal gait, mild cognitive impairment, requires a walker and wheelchair, is able to self-transfer out of bed or chair, and is a high fall risk. Licensee and Administrator stated that although the physician’s report documents that R1 is able to self-transfer, that determination might not be accurate because the physician’s report was completed at a skilled nursing facility and not by R1’s primary care provider. S2 stated that S1 does not like to leave wheelchairs by residents’ beds so that residents are more inclined to call staff for transfer assistance rather than attempting to transfer alone. S2 stated that this has prevented many falls, but that they told S1 to leave the wheelchair by R1’s bed anyway due to R1’s request. Staff #3 (S3), Staff #4 (S4), and the Administrator confirmed that R1 had 1-2 falls when R1 first moved into the facility, but that there have not been falls within the last month. S3 stated that R1 is alert sometimes, but also has moments of forgetfulness where R1 cannot recall events, repeats phrases, and exhibits dementia symptoms. During staff interviews, S1, S2, and Staff #5 (S5) who showered R1 on 11/16/2024 and 11/13/2024, stated they did not observe any marks or bruises on R1. Licensee and Administrator stated they were not aware of any marks or bruising on R1. However, at 3:48PM, LPA observed a 2-inch purple bruise on R1’s upper right arm with larger yellow and green hues surrounding the purple mark. LPA asked R1 about the bruise, R1 initially stated they were punched by a staff member but then stated that they do not remember where the bruise came from. LPA reviewed a body check conducted by Guardian Angel Home Health on 10/22/2024, that documented that R1 did not have any bruising. Based on interviews, record review, and observation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Physical abuse by staff led resident sustaining a large bruise” is deemed UNSUBSTANTIATED at this time. No deficiencies issued. Exit interview conducted. A copy of the report provided.