Complaint Investigation Report

Regarding Allegation #1 : Resident sustained unexplained injuries due to lack of staff supervision.

This complaint alleged that due to staffing issues R1 had an unexplained injury while in care. A1 indicates that A1 received notice from staff that R1 had an unexplained bruise to R1 right arm. A1 indicates that on 03/22/2024 R1 husband W2 took R1 for a walk. R1 appears to have fallen and injured R1 right eye and arm. A1 indicates that W2 did not inform A1 of the fall and injury and the next day staff noticed the injury and reported the incident to R1 family and wrote an incident report. A1 indicates that there are no staffing issues. S1 indicates that any injury to a resident is reported to resident family and an incident report is generated. S1 indicates that there are no staffing issues and the unexplained injury to R1 was not from lack of staff. R1 no longer lives at facility and could not be interviewed. R2 was non-verbal and could not answer any questions. R3-R5 indicates no staffing issues and staff take care of their medical needs. W1-W2 indicates that R1 had an unexplained injury under care from the facility. W1-W2 indicate that R1 injury was due to staffing issues.

Regarding Allegation #2 : Staff did not address residents change in condition. This complaint alleged that staff did not address R1 change in health condition. A1 indicates that R1 health was changing and A1 had a conversation with R1 family and that a review would be needed. A1 indicates that R1 was aggressive with staff due to health condition and new medication would be needed. S1 indicates that R1 change in condition was addressed and S1 advised A1 and R1 family of R1 health changes. R1 moved and could not be interviewed. R2 was non-verbal and could not answer any questions. R3-R5 indicates that staff does keep records and address changes in their medical condition. W1-W2 indicate that staff did not address changes in R1 condition and R1 family had to complain. Reviewed R1 records which indicate: Review letter from administrator to residents’ family (date 3/26/2024), letter indicates injury to resident right eye lid, appears resident hit herself on unknown object and did not inform staff. Reviewed email from A1 regarding R1 (date 12/12/2023) regarding reassessment and level of care for resident. Email communications also regarding diet and care.