Complaint Investigation Report

On 10/31/24 at 7:30 a.m. facility staff went into R1’s room to get him up for the day and found R1 was unresponsive. 911 was called and R1 was taken to the emergency department and later admitted to the hospital with a diagnosis of sepsis. R1 was discharged from the hospital on 11/15/24 and returned to the facility. On the morning of 11/16/24 staff found R1 unresponsive and called 911. R1 was taken back to the hospital and remained there until his death on 11/27/24.

On 11/18/24 W2 reported via a SOC341 that she interviewed R1 who stated via white board that he was physically hurt in the anus with foreign objects by S2 at the facility.

The Department interviewed W1 who stated that he interviewed R1 at the hospital. R1 confirmed to W1 that he felt something had been inserted in his anus. R1 also stated to W1 that he felt S2 did not mean to hurt him and that he wants to return to the facility.

On 11/25/24 the Department interviewed R1 at the hospital via white board. R1 denied that S2 had ever touched him inappropriately or put “something in him.” R1 became visibly annoyed by the question by furrowing his brow and turned away from Department staff and concluded the interview by writing “thank you” on the white board.

LPA interviewed 3 facility staff: S1, S2 and S3: S2 and S3 were R1’s primary caregivers. All 3 reported that R1 was happy at the facility and never had any complaints about his treatment over the 11 years he lived at the facility. S2 was the staff person who changed R1’s diaper on a daily basis for the last 7 years. S2 stated that R1 never had any issues with the daily routine, and it went smoothly. LPA asked if anything has ever been inserted into R1’s rectum and all 3 replied “no.” LPA also asked S2 if he ever got “rough” while changing R1’s diaper, S2 replied “no, I was always as gentle as I could be with R1.”

This agency has investigated the complaint alleging staff roughly cleaned resident and staff inserted an object into resident’s anus. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED .

Exit interview conducted, a copy of this report provided.