Complaint Investigation Report

First allegation: Resident sustained unexplained injuries while in care

This investigation consisted of observation, interviews, and record review.

It was stated that R1’s family member had unexplained bruising on their knees. Staff 1 (S1) stated that the bruises on R1 were old bruises, and those bruises were not recent. LPA Hayes interviewed PZ1 and asked them if they were aware of any conversation or incident with their family member or S1 regarding unexplained injuries with their family member or other residents in the facility and they said they were not aware of this. LPA interviewed Nurse 1 (N1) and they stated the allegation that a resident sustained unexplained injuries that they have no specific knowledge of this. LPA Hayes observed that R1 was admitted in the facility on 02/12/25 through records review of the Admissions Agreement. LPA Hayes learned that R1 was taken out of the facility shortly after this incident involving R2 on and left the facility on 03/10/25. LPA Hayes also observed no additional incident reports involving R1 was sent to the Department by this facility Administrator. No additional evidence was found for this allegation. The preponderance of evidence standard has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED.

Second allegation : Staff did not seek medical attention for injured client

This investigation consisted of observation, interviews, and record review.

LPA Hayes interviewed one staff, R2’s POA (PZ1), R2 and the Hospice Nurse (N1) and the Reporting Party (RP).

The Reporting Party (RP) alleged that the Administrator was negligent for failing to call Emergency Medical Services (EMS) for the injured resident. PZ1 stated that when the incident occurred, Staff 1 (S1) immediately contacted them and sent photographs of the resident’s injury. PZ1 reported that after reviewing the photographs, the injury did not appear to “be that bad”. PZ1 stated, “It was not that bad. It didn’t look like she needed to go to the hospital.” Through a file review, LPA Hayes confirmed that S1 is a licensed registered nurse. LPA Hayes attempted to interview R2 regarding their experience. They stated that they did not go to the hospital after the injury. LPA Hayes interviewed (N1) and they stated that regarding the allegation that staff failed to seek medical attention, they did not have specific knowledge of how that situation was handled. The preponderance of evidence standard has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED.