Complaint Investigation Report

The investigation revealed the following: Regarding allegation “ Resident sustained unexplained injury due to staff neglect/lack of supervision ” it was reported that R1 was observed to have several unexplained bruises to the body including bruises to the chin, left temple and a large black and purple bruise located on the inner thigh, halfway to the knee. Based on file review and interviews conducted by the Department, there was insufficient evidence to suggest the bruising on R1 was a result of staff neglect. R1 has a known behavior of climbing over bed rails and getting out of bed. At the time of bruising, there were no doctor’s orders for 1:1 supervision. S1 stated they believe that the medications R1 was taking may have contributed to R1 being more of a fall risk and increase R1’s chances of bruising when R1’s skin touches the rails on her bed, walls, wheelchair handles, etc. Due to cognitive ability, R1 was not able to answer the investigator’s questions. R1’s family do not feel staff was negligent and feel staff is caring for R1 appropriately.

Based on interviews and record review, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to Gregg Knapp.