Complaint Investigation Report

Witness (W1) reported it to Staff 1 (S1). R1 resides in memory care which has a secure perimeter with delayed egress exits. S1 attempted to assist R1 but R1 was not responding to S1. S1 called for Staff 2 (S2) to assist. W1 reported to law enforcement that S1 and R1 began punching each other. W1 reported to LPA that they did not actually see S1 hit R1 but assumed they were being hit because R1 was yelling. W1 reported to law enforcement that R1 was yelling, “Kill her. Kill her.” W1 reported to LPA they didn’t remember what R1 said. S1 reported that R1 had defecated in the hallway, and they wanted to get them out of their clothing and shoes because they were soiled. S1 stated that R1 became combative and tried to hit them. S1 stated that R1 started to lose their balance and started to fall so S1 held them up so they would not fall. S1 stated that they called S2 who came and took off R1’s shoes and asked R1 to walk to their room and R1 started to walk to their room. S1 and S2 both reported that once in the room they showered R1, put clean clothes on R1 and put R1 to bed. S1 denied hitting R1 and reported they have never abused any residents. S2 reported they did not witness S1 hit or abuse R1 in any way. No other staff members or witnesses were present during the incident. Law enforcement took a report on September 23, 2021, but did not take any action. LPA attempted to interview R1 but R1 did not recall the incident. Based on the evidence gathered, the allegation is deemed Unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.

The investigation into the allegation, resident sustained injuries while in care, revealed the following. It was alleged that Resident 1 (R1) sustained bruises on their forearms which were caused by facility staff. R1 was interviewed but did not recall how their arms were bruised. 5 out of 5 staff interviewed were unaware of R1 bruising until they were told about it. 5 out of 5 staff interviewed denied causing any injuries to R1 or any residents. The General Manager stated that R1’s responsible party informed them of the bruise and asked staff about it but no one could explain how it occurred. None of the staff interviewed could explain how R1 sustained their bruises. R1 resides in memory care which has a secure perimeter. R1 is on 2 medications, that can cause bruising, Quetiapine Fumarate and Lorazepam, but it is rare. The facility does not have any surveillance cameras. R1’s responsible party reported the unexplained bruises could have been caused by facility staff. The facility General Manager reported that they spoke to memory care staff, and no one reported any falls or incidents regarding R1 that could explain the bruises. LPA toured the memory care unit and R1’s room. No obstacles or hazards were observed.