Complaint Investigation Report

Regarding the allegation “Staff handled resident in a rough manner”, it is being alleged that on 11/20/2024 Staff 1 (S1) handled Resident 1 (R1) (who has dementia and wanders) in a rough manner. Interviews conducted revealed the following: Staff 1 indicated that they placed their arms underneath R1’s arm pits and walked behind R1 to take them out of another resident’s room. Witness 2 (W2) indicated that they saw R1 go into another resident’s room and S1 did not redirect R1 but instead S1 took out R1 by holding both hands behind R1’s body. Witness 2 explains that they did not clearly see what happened but is certain that S1 physically removed R1 from the other resident’s room. Witness 1 (W1) indicated that they saw R1 walk into another resident’s room. Witness 1 goes on to explain that S1 grabbed both of R1’s arms behind their body and then pushed out R1 with their upper body. Three staff who were not witnesses of the incident indicated that they heard a similar story of the incident. During interviews conducted with staff, staff gave examples of how to redirect residents with dementia and none of the examples involved physically touching residents. Records reviewed of the Facility "Dementia Care Plan of Operation for Regency Palms Long Beach" state the following:

“Respect the Individual: In addition to specific “resident rights” outlined in state regulations, we advocate the following rights for all residents: Freedom from…physical restraints o Freedom to move without being confined including space…3. Special Techniques/programs for managing specific types of behavior. In order to provide optimal care…Agitation…wandering…can become difficult management issues…Appropriate behavioral interventions can include: Offer a snack, sensory stimulation, 1 on 1 interaction…Wandering: daily living skills, walking, dancing…”

The Facility “Dementia Care Plan of Operation for Regency Palms Long Beach” provides 20 different examples of redirection when residents are wandering. Moreover, none of these examples indicated physically touching a resident nor physically relocating a resident. Furthermore, S1 did not follow the Facility’s “Dementia Care Plan of Operation for Regency Palms Long Beach” because they indicated they used “physical restraints” by physically removing R1 from a resident's room. S1 did not use “Appropriate behavioral interventions” at outlined in the “Dementia Care Plan of Operation for Regency Palms Long Beach.” Regarding the allegation “Staff handled resident in a rough manner”, the preponderance of the evidence standard has been met therefore the allegation is substantiated.