Complaint Investigation Report

Regarding allegation: Resident sustained injury due to staff handling resident in a rough manner.

It was alleged that resident sustained a skin tear on right arm about 2-3 inches long on 4/29/2023. Based on the Department’s records review, R1 was admitted to the facility on 2/8/2023. R1 is diagnosed with a dementia. The department interviewed six (S1-S6) staff, three residents (R1-R3), and two witnesses (W1-W2). Six staff (S1-S6), two residents (R2-R3) denied that R1 sustained injury due to staff handling resident in a rough manner. R1 claimed S6 grabbed R1’s arm roughly and verbally threatened R1. S5 stated R1 was noticed with a skin tear after a routine diaper change. S5 stated two staff (S5 and S6) assisted R1 with diaper change to provide extra care for R1’s fragile skin. S5 stated the cause of R1’s skin tear is unknown and unnoticed. During interview with S6, the department observed S6 was stuttering and had difficulty speaking. S5 informed the department that S6 has a difficulty in speech but S6 is able to perform the assigned tasks. W1 and W2 revealed R1 has sensitive and fragile skin and R1 had prior skin tear on right forearm in a different facility. W2 stated R1 sustains bruises due to medications and skin condition. Based on gathered information, there is no sufficient evidence that r esident sustained injury due to staff handling resident in a rough manner.

Based on information gathered, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the above allegation is Unsubstantiated.

An exit interview was conducted with Area Manager Irene Formentera and a copy of the report was provided.