Complaint Investigation Report

LPA's interview with staff at 10:35 AM revealed that they observed that R1 was somehow getting weaker, so they started using the wheelchair even inside the facility beginning in mid-January. Further interview revealed that on 01/31/23 S1 was assisting R1 to transfer from the toilet to wheelchair in the bathroom, S1 locked the wheelchair from the back and about to pull R1 from the back of the wheelchair to situate R1 properly but R1 slid and fell instead. On 02/01/23, S1 assisted R1 to transfer from the wheelchair to the toilet but when R1 was already seated, S1 reached out for hygiene supply located in the drawer about two and a half (2 1/2”) feet away from R1 but R1 let go of the grab bar and fell sideways of the toilet. S1 staff was present and trying to help R1 on both occasion when R1 fell. LPA's interview with administrator at around 11:00 AM revealed that the facility immediately implemented a two (2) person assist to R1 after the second incident. LPA's record review confirmed that the two (2) persons assist to R1 was immediately implemented.

Based on the information gathered during today's visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.