Complaint Investigation Report

Record review revealed of Unusual Incident Report (03/17/26) revealed according to R2 and Resident #4 (R4), R1 spit on R2 and the physical altercation occurred. Staff #2 (S2) separated both residents and called 911. Long Beach Police Department described the incident as a “mutual altercation” and no arrests were made. Hospitalization was offered and R1 and R2 declined. R2 complained of shortness of breath and went to the hospital around 9:15 PM that night. R1 was transferred to LA Downtown Medical Center on a 5150 hold, danger to others, the following day. Review of Master Schedule revealed one Licensed Vocational Nurse, MedTech, and two caregivers were working Tuesday PM Shift (4:00 PM – 12:00 AM). Review of Attendance Roll (03/16/26 – 03/22/26) revealed R1 was present during the AM and PM attendance count on 03/17/26. R1's Preplacement Appraisal Information (05/22/24) revealed R1 does not need special observation/night supervision (due to confusion, forgetfulness, wandering). R1's Physician's Report (05/21/24) revealed R1 is able to leave the facility unassisted and has the capacity for self-care. Seven out of nine resident interviews (R1 – R2, R4 – R10) indicated there is sufficient staff supervision on the second floor and in the evenings. R2 indicated R1 spit on R2 because R2 made a comment as R2 walked past R1’s room. R4 indicated R4 witnessed the fight at the elevator and indicated R1 attacked R2. R6 heard the commotion but did not go outside of R6’s room to witness the altercation. R10 indicated R2 did not enter the room to attack R1 but R1 was outside the room sweeping. R10 indicated R10 could not see any injuries on R1. Nine out of nine staff interviews (S1 – S9) indicated there is sufficient staff supervision on the second floor and in the evenings. S2 indicated R1 approached S2 as S2 was exiting the elevator. R1 said R2 attacked R1 in room. S2 then saw R2 approaching them yelling and the two residents were separated. S2 indicated rounds are conducted every 90 minutes or sooner and staff does laundry on the second floor. S2 indicated caregivers were starting to assist residents with showers during the time of the incident. S3 indicated S3 cleansed R1’s bleeding, assessed R1 from head to toe, and provided an ice pack. R1 told S3 that R1 got into a fight and R1 declined the option to go to the hospital. S1 and S3 indicated rounds are conducted every two hours. LPA observed photo of R1 with bleeding on the side of the head and some bleeding on the face. LPA observed photo of R2 and R2 had a busted lip and bruised knuckles.

Regarding the allegation, “Due to lack of supervision, resident assaulted another resident causing injury,” based on record review, interviews and observation, the Department found no evidence to support the above allegation. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated .

An exit interview was conducted and a hard copy of this report provided to Admissions Director Nicole Lozano.