Complaint Investigation Report

Based on LPA’s records review, R1 was admitted to the facility on 2/1/2023. R1 is non-ambulatory, uses a wheelchair and not able to care own toileting needs and to bathe self. R1 is able to manage own prescription medications but prefers help from staff.

Regarding allegation: Staff caused bruises to resident in care.

Reporting Party (RP) reported staff constantly treat residents roughly, causing bruises.

LPA interviewed and obtained information from five out of six residents (R1-R6) and three staff (S1-S3). S1 stated there are four residents in the home that require assistance with activities of daily living (ADLs) either dressing, toileting, or transferring and other hygiene care. S1 stated S1 usually provides assistance to R5 and R6. S1 stated S2 and S3 usually provide ADL assistance to R1 and R3. S1 stated R2 and R4 require only minimal assistance with their ADLs. S1 stated however, any staff may assist any resident if needed. Interview with R1 and R3 revealed two staff (S2-S3) are rough when assisting residents with their incontinence and activities of daily living causing them bruises. S2 and S3 scrub residents’ body roughly until their skin turn red and staff put their weight on residents while changing residents’ diaper or clothes causing them bruises. S2 and S3 admitted they usually provide assistance to R1 and R3 with their ADLs, but they claim they handle them gently. Two other residents (R2-R4) and three staff (S1-S3) denied staff caused bruises on residents in care. R3 stated S2 and S3 cause resident bruises intermittently. LPA did not observe any bruises on R1 and R3 during the visit but based on LPA’s review of a photo taken on March 22, 2023, R1 had a circular light discoloration (bruise) on leg. Based on LPA’s investigation, there is sufficient evidence to prove that staff caused bruise on resident in care.

Regarding allegation: staff handles resident in a rough manner.

Reporting Party (RP) reported staff constantly treat residents roughly. Staff lean on resident’s body while providing assistance with their activities of daily living, pushing their weight onto the resident.