Complaint Investigation Report

Allegation: Resident sustained injury due to lack of care from staff

It is alleged that the resident had noticeable multiple bruises on their face, purple and green color, bilateral cheeks, right jaw, and noticeable swelling on right forehead from a lack of care from staff.

Based on record review, Resident #1's (R1) Physician Report dated January 24, 2025, diagnoses R1 with major depressive disorder and dementia. It is noted on Facility charting notes, many incidents with R1 having behavioral issues such as impulse behavioral issues and not following staff direction, which led to the incident where R1 had multiple bruises due to an unwitnessed fall.

Facility Incident Report dated on July 30, 2025, R1 was sent to the hospital due to an unwitnessed fall, falling face first to the ground. R1 was found to have full range of motion and hematoma to the right side of their face and a scratch on the bridge of their nose. Facility charting notes dated July 30, 2025, also confirmed the Incident Report, which stated R1 was sent to the hospital due to an unwitnessed fall where R1 fell to the ground face first with injury to their face. Hospital record dated on July 30, 2025, confirmed the fall and hematoma right forehead.

Facility Charting Notes dated on August 3, 2025, due to the fall from July 30, 2025, R1 was noted with skin discoloration to right eye, left eye, and cheek. It was noted R1 did not complain of pain or discomfort. Facility Charting Notes dated August 5, 2025, due to the fall from July 30, 2025, it is noted there is a continuation of facial discoloration and swelling from R1’s forehead. It is also noted a yellowish and greenish discoloration to the right side of face/cheek. Purplish and greenish discoloration to bilateral eye area. After Visit Summary hospital record dated on August 17, 2025, stated R1 was sent to the hospital on August 17, 2025 due to agitation, and was discharged from the facility on August 22, 2025. Facility Charting notes dated August 22, 2025, at 6:00PM, that R1 returned to the facility from the hospital. Prior to the hospitalization on August 17, 2025, Resident still had some bruises remaining prior to being admitted to the hospital.

Based on interviews, five staff denied the allegation. One resident could not confirm or deny the allegation. Five staff stated the resident did not sustain an injury due to lack of care from staff. Five staff stated the resident had behavioral issues due to impulse and agitation. Staff #1 (S1) stated that the R1 had a fall on July 30, 2025, and staff responded in a timely manner. R1 was sent to the hospital for the unwitnessed fall