Complaint Investigation Report

Note: There has been a change of Executive Director and Health and Wellness Director since the incident.

On January 12, 2024, at approximately 5:35 PM resident (R1) was sent to the emergency room and was discharged back to the community the following day on January 13, 2024, at approximately 5:30 AM. On January 13, 2024, at approximately 12:55 PM, staff observed R1 vomiting and complaint of neck and shoulder pain. Staff sent R1 back to the hospital. Documents indicated that R1 died at the hospital three days later on January 16, 2024. Corners report documented R1’s cause of death to be “probable sepsis” and “acute spinal fracture of T3 and T4 with epidural hemorrhage and acute osteomyelitis with spinal epidural abscess”.

According to statements and interviews conducted, On January 12, 2024, R2 had walked up to the nurse's station and became combative with staff. Staff observed R2 grabbing R1 by the wheelchair and pushing R1 towards the nurse’s station. Staff observed R2 slammed R1 into the nurse’s station door. R2 then pushed R1 down the hallway in their wheelchair. R2 went around the corner with R1 at which time staff heard R1 screaming. Staff came around the corner and observed R1 on the floor. Interviews with staff provided multiple accounts of the incident however, staff present did not attempt to redirect R2 from R1.

The Department conducted interviews with staff which regarding the protocol to take when two residents are having an altercation. Staff indicated they are to redirect and distract residents with something they like. Staff stated when two residents are having an altercation, staff are to intervene and separate the two residents as the safety of residents is a priority.

Based on the information staff provided regarding the altercation between R2 and R1, staff did not follow facility protocols and failed to ensure R1’s wellbeing and safety. Staff indicated R2 had a history of being aggressive physically and verbally. Documents reviewed revealed on October 23, 2023, at approximately 3:30 PM, R2 told another resident in care (R3) to get out of R2's room and pushed R3 down onto the hallway floor.