Complaint Investigation Report

LPA discovered during a review of R1's incident report that S1 applied ice pack on R1 and resident refused to go to the hospital. R1 was monitored closely by care staff and once staff observed swelling, S2 contacted non-emergency transportation. S2 contacted R1's responsible party and informed of wait time so S2 was instructed to call 9-1-1 by R1's responsible party instead.

It was alleged staff did not inform resident's authorized representative of injury in a timely manner. However, during record review of R1's incident report on 4/6/23, both R1's conservator and family member were both notified by S2 of the incident that occurred on 4/25/22. S3 stated S2 left a voicemail for R1's conservator then notified R1's family member.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegatio ns are UNSUBSTANTIATED .

Exit interview conducted and a copy of this report provided to Executive Director.