Complaint Investigation Report

LPA interviewed 7 staff S#1-S#7 including administrator. On 9/25/22 two staff S4 and S8 were attempting to change resident when resident fell to the ground and hit R14 face on R14 wheelchair footrest that were removed from R14 chair and were by the beside. Administrator stated she was not at facility when incident occurred and does not know how R14 got injured. S4 who was in the room when the incident happened stated she was helping S8 to get the R14 to bed and R14 was very agitated and didn’t want anyone to touch R14. S4 and S8 were able to get R14 in bed from wheelchair and R14 continues to fight with staff and yelling at them to not touch R14. S4 stated R14 struck S8 after we changed R14, and I went to get a dress from R14 closet and had my back turned and heard S8 yell and turned around to see R14 on the floor and R14 had thinks R14 struck R14 face on the wheelchair footrest. S4 stated she did her report and does not recall if R14 went to hospital that day. Supervisor S2 stated R14 was in chair and fighting the staff while they attempted to change R14. S2 stated R14 was in chair when R14 fell and that she may have hit the wheelchair footrest on the floor. Supervisor S3 did not remember what occurred. S5 (temporary Administrator) stated she didn’t know what happened. S5 stated that daughter was told about incident but not the extent of the injuries and did not recall the date. S6 stated she did not know anything about the incident. LPA attempted to contact S8 on more than 3 occasions and was unsuccessful. S8 is no longer employed at the facility. There were several differing explanations of how the bruises and injuries had occurred but none that fully explained what happened. Resident 14 was hurt, staff failed to properly assess R14 injuries, seek medical attention and did not send R14 to hospital until the next day. Therefore, based on the information gathered and the interviews conducted the allegation has been deemed Substantiated.