Complaint Investigation Report

It was alleged that the: Resident sustained injuries while in care, Staff did not properly assess resident's change in condition and Staff refused to seek medical attention for resident.

LPA reviewed Unusual Incident Reports for R1 from 3/07/2022, 3/30/2022 and 04/05/2022. On 3/7/2022 R1 shoved Resident #2 (R2) in the hallway near the theater. R2 also had a diagnosis of dementia, It was documented and Power of Attorney (POA) was notified. In the report it stated POA would notify physician regarding aggressive behavior.

On 3/30/2022 R1 had another incident with R2 in the dining room; hitting R2 with a book. 9-1-1 was notified and R1 and R2 were transported to the Emergency Room for further assessment. POA for R1 was notified and the facility Health Services Director (HSD) faxed physician of R1's continued behavior.

On 4/05/2022 a third incident occurred where R1 pushed R2 to the ground. 9-1-1 was called and fire department and paramedics arrived. Police officers also responded and gathered witness statements. R1's POA was notified. In the incident report it is documented that R2 never provoked R1, and that a family conference was requested. On 4/06/22 R1's POA picked up resident and brought R1 to the hospital for a psychiatric evaluation. R1 did not return to the facility.

After the first incident on 3/7/2025, the resident returned with new medications. The Executive Director spoke directly to the POA regarding a personal companion and requested an evaluation with a neurologist regarding behaviors to conduct a re-appraisal of R1's change of condition. HSD stated the POA never took R1 for assessment and that a statement made by POA made HSD realize R1 had a history of physical aggression that was not disclosed per Physician's Report. Medical Technicians (MedTechs) continued to communicate with the Primary Care Physician (PCP), per incident report and HSD interview, regarding R1's behavior. Per HSD interview, R1 did not sustain injuries and that is was R2 who sustained injuries due to R1's behaviors.

The allegations that: Resident sustained injuries while in care, Staff did not properly assess resident's change in condition and Staff refused to seek medical attention for resident are Unsubstantiated.