Complaint Investigation Report

During the course of investigation, LPA L. Fontanilla did the following:

1. On 3/23/22 interviewed Executive Director

4. On 3/22/22, reviewed video footage of incident, needs and services plan, admission agreement, Physician’s Report

Based on interviews conducted with S2 and S3, they confirmed with LPA that they were working night shift on 6/19/2020. One is assigned to stay in the hallway to redirect residents and one stays with resident in the TV room. S2 is the assigned caregiver to stay with R1 in the TV room when the incident happened. S2 and S3 confirmed with LPA that R1 was already in the TV room when they started the shift. Both S2 and S3 state that R1 is ambulatory but they would always escort R1 in going to the restroom because R1 is unsteady.

S2 confirmed with LPA that S2 was in the same room with R1 during the incident but did not notice R1 get up and walk. S2 states S2 was sitting facing the wall. When LPA asked S2 the reason for facing the wall, S2 states “I don’t know why I was facing the wall.”

A review of R1’s Personal Service Plan Assessment dated 06-20-2020 indicates R1 needs transfer assistance requiring 1 caregiver if needed with:

The Service Plan also indicates staff will conduct periodic checks on R1 at bedtime when resident is sleeping in the room. And that R1 needs to be monitored for balance and safety.

A review of the video footage from the incident shows R1 sleeping on the chair in the TV room.