Complaint Investigation Report

Allegation: The resident sustained unexplained injuries while in care.

Regarding the allegation resident sustained unexplained injuries while in care. It is alleged that the resident was admitted to Kaiser Permanente Medical Center for pneumonia and was observed to have various discolorations of unknown etiology (Mark) on the body. The department interviewed the Administrator #1 (A1) who stated that on 10/30/24, the Power of Attorney (POA), moved the resident #1 (R1) out of the facility and did not let A1 know where R1 would move. On 12/09/24, the department called and spoke to the (POA) over the phone who stated that POA remove R1 out of the facility due to medical necessity and personal reasons. The POA also stated that on 10/30/24, R1 did not have any discoloration or bruises on the body. The staff was very kind and took good care of R1 while residing at Everlasting Home Care. The hospitalization happened on 11/28/24, while R1 was at the new facility, The Villa. When the nurse observed R1, had pneumonia and called the paramedic who transported R1 to Kaiser Permanente Medical center and on the same day R1 was admitted. The department interviewed two residents (R2-R3) 2 out of 2 stated that they enjoyed living at the facility. The department interviewed two staff (S1-S2) 2 out of 2 stated that they do not restrain residents. The department interviewed the Independent Care Management Witness #1 (W1) who stated that W1 visits R1 twice a month at the facility and did not observe any discoloration or bruises on R1.