Complaint Investigation Report

R1 passed away on 11/7/2024 as a result of complications of the procedure.

Interview with witness indicated during the 911 call staff (S2) stated R1 fell as a result of being pulled or pushed by another resident (R2). However, interview with staff (S2 and S3) revealed that they did not know how R1 fell. S2 stated he did not know why he reported during the 911 call that R2 pulled or pushed R1 to the floor and R2 did not say that she pushed R1. S2 does not know how R1 ended up on the floor, but R2 reported that R1 had fallen. S3 stated R1 had a history of falls prior to the incident on 11/2/2024.

Interview with staff and residents revealed that R2 did not have a history of physical aggression towards residents or R1. Residents (R3 and R4) stated R1 would walk into other resident’s rooms and take their belongings. Staff (S2 and S3) stated R2 would get upset with R1, but R2 was only seen to be verbally aggressive towards R1.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED .

Exit interview conducted with Janice Gombio. A copy of this report was provided.