Complaint Investigation Report

The details of the complaint reported on 08/03/24 that client #1 (C#1) had sustained unexplained bruising while in care at this facility. (C#1) was found with suspicious bruises in the perineal area of the body. The report did not provide any further details.

Investigation revealed client #1 (C#1) was admitted at Bay Breeze Care on 12/20/22 according to Identification and Emergency Information (dated: 12/20/22). (C1) voluntarily terminated residency from Bay Breeze Care on 08/05/24. Physician’s Report (dated: 01/29/24) and Preplacement Appraisal Information (date: 12/18/22 & 01/29/24) identified (C1) can self-care and is independent and requires assistance only with dispensing medications.

On 08/03/24 at 08:30 am, (C#1) was hospitalized at College Medical Center due to Dysarthria and Essential tremors. Medical information revealed (C#1) observed bruises in the perineal area of (C#1’s) body.

On 08/09/24 between 09:15 am - 09:45 am, the Department interviewed (3) out of (3) administrators #1-#3 (A#1-A#3) who reported having no knowledge of (C#1) sustaining bodily bruises. (A#1-A#3) described (C#1) as independent and with minimal social interactions with other residents or staff. (A1) claimed that (C#1) is ambulatory and requires no assistive devices. (A#1-A#3) stated that (C#1) was not on any required medical restraint while in care. (A#1-A#3) stated that (C#1) had no accidents, falls, or physical altercations while in care. (A#1-A#3) reported that (C#1’s) out of the community involvement consist of performing domestic errands.

On 08/09/24 between 10:16 am -11:16 am, the Department interviewed (6) out of (6) clients #2-#7 (C#2-C#7) who claimed to have never experienced or know clients that have sustained bodily injuries/bruises while in care. (C#2) who shared a room with (C#1) claimed that (C1) never mentioned any pain from injuries or sustained bruises. (C#2) did mention that (C1) did have some skin rashes that were under control on medically prescribed ointments. (C#2-C#7) were complimentary of the staff and stated the staff is responsive to the client’s medical attention when it is required.

On 08/09/24 between 11:17 am -12:40 pm, the Department interviewed (3) out of (3) witnesses #1-#3 (W#1-W#3) who had observed or were aware of (C#1’s) bodily bruises. Licensed vocational nurse (LVN), (W#3) indicated that (C1) had a rash for several months, and it was being treated with a prescribed Hydrocortisone.