Complaint Investigation Report

9099C-1.. The complaint relates to resident (R1) who moved to the care home on 9/12/24 and was sent out to the Emergency Room on 9/15/24. Resident's Physician's Report notes (R1) had a diagnosis of: Diabetes Type 2; Chronic Systolic Congestive Heart Failure; Delirium without Dementia and Mild Cognitive Impairment. The report further indicates (R1) was able to follow instructions, communicate needs, was non-ambulatory (due to their physical and mental condition) and was not able to leave the facility unassisted.

Allegation: Staff handled resident in a physically inappropriate manner. The complaint alleges that sometime from 09/12/24 -09/14/2024 facility staff (S1) yanked (R1) by their shirt when they tried to go outside for a walk, which caused (R1) to fall on the ground.

Staff (S1) stated she worked with (R1) from Thursday thru Saturday after (R1) moved in on Thursday evening, 9/12/24, around 4:00 pm. (S1) stated (R1) was "very rude and disrespectful" to her and other staff, explaining (R1) pulled the gate open and hurt (S1's) toes and punched (S1) and was also verbally abusive. (S1) stated (R1) walked without a walker, would curse, disrobe and throw things, including their diaper on the floor, asserting (R1) "was strong with a big build". (S1) stated she knows how to "maintain professionalism" and she kept quiet when (R1) was yelling and "never slapped (R1) or hit her", stating "I don't do those things".

The House Manager stated the Administrator, Leyla, was present when (R1) was pulling at the outside gate and wanted to leave and called 9-1-1 and then (R1's) family, commenting "it was very concerning when (R1) tried to leave since the facility is located on a busy street". The House Manager stated there was no police report taken, (R1) was "happy to move in and didn't seem to have problems" and (R1) was "okay the first two days".

The Administrator at the time stated that after the first two days,(R1) was "walking around naked and taking off their diaper", explaining that when (R1) was at the hospital, prior to being admitted to the care home, , she assessed (R1) and "no one told me they had behaviors- (R1) changed quickly- maybe (R1) had a UTI- because the last two days, we couldn't control (R1)". The Administrator asserted (R1) "was the aggressor with (S1)" and "hurt (S1's) foot".

(R1's) family member stated she received a phone call from staff just (2) hours after dropping (R1) off on 9/12/24, asking her to pick (R1) up as (R1) tried to leave the facility and broke (S1)'s toe. The family member stated (R1) uses a walker and when (S1) went outside with another client to get some sun, (R1) tried to leave. *cont on 9099C-2...