Complaint Investigation Report

Interview with the former ED revealed it was reported that R2 bumped into R1, but the former ED never witnessed it. The former ED stated the facility was aware of R2’s aggressive behavior. The former ED spoke to R2 about the behavior and sent emails to staff to “keep an eye on" R2, but R2’s plan of care was not updated. Record review of R2’s physician’s report revealed R2 had aggressive behaviors and a diagnosis of dementia. Interview with S1 revealed R2 hit S1 with their walker when they got upset. S1 confirmed that the former ED sent staff an email on how to address the behavior, but staff did not receive a formal training. Interview with R2 at 10:20 a.m. on 11/01/2024 revealed they had never hit anyone. Interview with Staff #2 (S2) at 10:45 a.m. on 11/01/23 revealed they witnessed R2 hit S1. Interview with Staff #3 (S3) at 3:15 p.m. on 11/01/23 revealed they had been hit by R2 as well, and the former ED did nothing about it. Interview with the current ED revealed the facility updated R2’s plan of care i January of 2024 and trained staff at the same time. Based on interviews and record review, the facility did not prevent R2 from hitting others. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the attached LIC 9099-D page and cleared due to prior corrective action.

No immediate health and safety risks were observed.

Exit interview conducted. Appeal rights discussed. Copy of report provided.