Complaint Investigation Report

Allegation: Staff did not prevent a resident from attacking another resident.

The details of the complaint alleged resident #1 (R1) was attacked and the facility staff failed to prevent the physical assault. The complainant reported (R1) was physically assaulted by a another resident and sustained abrasions and lacerations on the front of the leg. The complainant did not provide further details on this matter.

Investigation revealed resident #1 (R1) came from Ocean Ridge Post Acute a skilled nursing facility. According to resident #1 (R1’s) Identification and Emergency Information LIC 601 (dated: 06/07/24) was admitted to Vista Del Mar on 06/07/24. (R1’s) Physicians Report LIC 603A (dated: 06/07/24) is non-ambulatory and requires assistance services with medication, transferring, bathing, dressing, and grooming.

On 07/18/24, between 09:30 am – 02:00 pm, the Department interviewed (5) out of (5) Executive Director #1(ED1) and staff #1-#4 (S1-S4) claimed this allegation was false. (A1 and S1-S2) claimed there was no physical assault that took place between resident #1 (R1) and resident #2 (R2). (S1-S2) reported that (R1) had an unwitnessed fall on 07/07/24 at 07:00 pm, (R1) sustained a minor skin tear on the leg and was assisted by a facility licensed vocational nurse/med-tech. (S1-S2) stated the skin tear was minor and did not require hospitalization. On 07/08/24 at 10:00 am, when being assisted by the care staff experienced combative behavior and delusional hallucinations and needed further medical evaluation according to the facility medical physician and was sent to College Medical Center on a (5150). (S3-S4) primary caregivers to (R1), explained that (R1) has displayed combative behavior when assisted with daily activity services. (S3-S4) stated (R1) had an intense fear of being touched and would respond by acting in inappropriate physical behavior with staff. (S2) reported when (R1) was admitted to Vista Del Mar from Ocean Ridge, (R1) already had multiple skin problems. (R1) is taking Eliquis, a blood thinner that can cause bruising and skin tears. According to (S2), both (R1) and (R2) require medical devices or mobility support as they are non-ambulatory. (R2) was diagnosed with Paralysis, which is a loss of muscle function in part of the body that would limit (R2's) ability to move, causing no physical assault on (R1 ). (S2) indicated that the facility's physician modified one of (R1's) prescribed medications to help improve (R1's) disorderly behavior on 06/21/24. (Evaluation Report continues LIC 9099-C)