Complaint Investigation Report

Allegation: Staff handled resident in a rough manner resulting in an injury. It is alleged that on 5/30/2024, resident (R2) left the Memory Care Unit to the Assisted Living side of the facility and staff (S10) grabbed the resident's arm in a rough manner that caused injuries. According to information obtained, staff (S8) was terminated because of their actions. A total of 8 residents were interviewed. Two (2) out of 8 residents stated that former staff (S8) handled residents in a rough manner. A total of 7 staff were interviewed. Staff interviewed reported knowledge that former staff (S8) handled resident in a rough manner. Administrator Bautista stated staff (S8) was terminated due to excessive absences. Therefore, S8 was not interviewed. Staff interviews revealed that R2 was being transitioned into the memory care unit from the AL unit and often tried to elope by pushing hard the delayed egress doors. Staff (S8) grabbed the resident away from the door and as a result caused shoulder bruising. Staff interviewed stated R2 takes blood thinner medications that make the resident susceptible to bruising. In addition, according to information obtained on a different date S8 was observed being forceful when trying to get R2 in the bath. Based on interviews conducted on 5/30/2024, S8 used rough physical contact instead of redirection techniques. There is sufficient evidence to corroborate the allegation.

Allegation: Staff did not prevent a resident from falling out of a window. It is alleged that in July 2024 Memory Care Unit resident (R1) climbed out of a bedroom window due to lack of supervision. A total 7 staff were interviewed, of which all staff confirmed the incident. Based on record review and interviews conducted the findings indicate that on July 1, 2024, at approximately 6:30 PM cognitively impaired resident (R1) attempted to elope by going out of another resident's bedroom window in the 1 st floor Memory Care Unit. The resident fell and hit their head while climbing out the window. The resident sustained an open laceration to forehead and a dislocated shoulder. Memory Care Staff did a resident count and noticed the resident was missing and went looking for the resident. Resident (R1) was found outside the facility on the steps of the right side of the building. The resident was bleeding from the head and 911 was immediately called. According to staff interviews, on the date of the incident there were 3 staff in charge of supervising 22 Memory Care residents. One (1) staff was out to lunch, another staff staff was doing incontinence changes, and the 3rd staff was responsible for watching the residents that were in the dining/activity area. The staff watching the residents in the activity area had to leave to the restroom to assist a resident. The findings indicate that at that time six (6) residents in the Memory Care Unit were a fall risk and staff were not to leave them unsupervised. There is sufficient evidence to corroborate the allegation.