Complaint Investigation Report

Regarding allegation Staff caused injuries to a resident while in care , It was alleged that Resident 1 (R1) sustained bruises due to improper handling of Staff 1 (S1). Per interviews conducted with staff members, two of three staff stated that they helped assist R1 when they asked for help. Three of three staff interviewed stated that Staff 1 primarily handled R1 and that R1 was “full assist”. Three of three staff members stated that they never noticed bruising on R1’s body. Per interview with S1, states they never handled R1 in a rough manner and that R1 was very alert. Three of three staff stated that they never witnessed other staff mishandling R1 while in care. During initial visit conducted on November 24, 2021, LPA toured facility physical plant and observed residents relaxing inside bedrooms watching television. LPA observed R1 inside bedroom on recliner chair and did not observe any visible bruising on R1’s body. LPA was unable to interview R1 due to R1 resting on recliner at time of visit. LPA attempted to interview other residents but due to their medical condition’s interviews were not successful. The LPA attempted to identify and contact R1’s family members for interviews, however, no information was available during record review.

Per Record Review, LPA Tirre did not observe any incident reports related to alleged injury for R1.

Regarding Allegations Resident is left unattended for extended period of time and Resident incontinence needs are not being met while in care. It was alleged that R1 was left alone for long periods of time that they often had incontinent accidents due to not being taken to the bathroom. Investigation revealed the following: Per staff interviews, Three of three staff stated R1 was never left unattended due to facility always had staff present inside the facility. Three of Three staff stated that R1 needed full assistance with areas of daily living including toileting and staff stated they were available to help R1 whenever needed. One of three staff interviewed stated that resident wore pull up underwear and was not left soiled for periods of time. One of three staff stated they could not recall if R1 had incontinence issues. During visits to facility, LPA observed two staff members on duty who were attentive to residents’ needs. One staff member was checking on residents in bedrooms while another staff member was supervising other residents in common area.

The LPA attempted to identify and contact R1’s family members for interviews, however, no information was available during record review.

During Department visits, Department reviewed Resident records and observed that R1’s Physician’s report dated May 3, 2021, stated that R1 had diagnosis of Spinocerebellar ataxia stating R1 was wheelchair bound and fall risk. Physician’s Report also stated that R1 does not require continuous bed care and is able to communicate their needs.