Complaint Investigation Report

9099C-1. Allegation: Facility staff failed to properly supervise residents resulting in resident being attacked and hospitalized for injuries. The allegation states on Sunday, March 30, 2025, a resident walked into the resident's (R1's) room while (R1) was sleeping and attacked (R1) who sustained a fractured vertebra and a dislocated joint in the hand.

Staff interviews conducted and documentation reviewed confirmed that on March 30, 2025, resident (R2) entered (R1's) room, at approximately 9:30 am, and physically attacked (R1) while (R1) was sleeping. Staff who was present and observed (R2) enter (R1's) room stated they followed (R2) into the room one to two minutes later and observed (R2) to be standing over and hitting (R1) who was resting in bed. Staff called for a second staff to assist with separating the residents from each other. Both residents were sent out for further medical evaluation following this incident.

Medical records note that (R1) was sent out to the emergency room at one hospital and diagnosed with “Scapholunate dissociation, unspecified laterality (primary encounter diagnosis), Closed compression fracture of L3 lumbar vertebrae, initial encounter, Rib pain. (R1's) family member confirmed that (R1) was diagnosed with a fractured hand/wrist and fractured lower back. Documentation reviewed confirmed that (R2) was sent to a different hospital and diagnosed with a "behavioral problem". Interviews and documentation concluded that (R2) has a known history of aggression towards residents and staff and had previously attacked (R1) on at least two separate occasions.

The Department was told by (3) facility staff during interviews that (R2) should have been placed in a higher level of care facility, such as a skilled nursing facility. Further, interviews and documentation revealed that although (R2's) initial placement was appropriate, (R2) had several changes in condition, including increased aggression, wandering and sundowning and should have been removed from the facility.

After the third unprovoked altercation between (R1) and (R2) the facility began to implement 1:1 care/supervision with (R2), which is not a service the facility provides, and began hiring a staff to provide the this care/supervision through an outside agency. The facility failed to implement reasonable and timely interventions to mitigate known risks, leading to neglect.

Based on information obtained during the investigation, the Department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. *cont on 9099C-2..