Complaint Investigation Report

During interviews with staff, staff stated that on 03/23/24 R1 entered R2’s room and they were holding on to each other, when R2 took a step forward R1 was propelled backwards and fell injuring themselves. 911 was then called and police, fire and rescue showed up. Record review revealed R1 requires safety measures to address behaviors such as wandering. Staff were not aware of what was happening until R2’s roommate Resident #3 (R3) went to get staff. Staff were not paying attention to cameras and were not aware of what was happening.

Based on interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Being that this is the second time that this citation is issued in less than 12 months LPA explained to ED that this will be a repeat violation with a civil penalty of $250.

Citation was issued. Appeals rights discussed and provided. Exit interview was conducted and a copy of the report was issued.