Complaint Investigation Report

Records review further revealed an incident report was submitted to CCL on April 4, 2025. Incident report stated that on April 3, 2025 at 435pm facility staff found R1 lying supine in front of room #144. R1 was assisted to their feet and advised staff that they did not know what happened but R2 was seen walking away from the area. Resident 3 (R3) then asked R2: "why did you do that to my friend?" R1 sustained a hematoma to their head as a result of the fall. Review of R2's care plan revealed R2 had a history of agitation evidenced by: swinging, hitting, yelling and cursing at staff.

LPA attempted to interview R1 on April 11, 2025. R1 was unable to answer qualifying questions. R1 was unable to state the date or time. LPA then asked R1 basic questions regarding their recent fall. R1 questioned "who fell?" LPA asked R1 if they had fallen recently and hit their head. R1 stated that they did not think that they had fallen recently and that they were fine.

LPA attempted to interview R2 on April 11, 2025. LPA asked R2 several qualifying questions. R2 began to speak unintelligibly while simultaneously pointing to different areas of their room. LPA asked R2 if they recalled pushing R1 to the ground. R2 again speaking unintelligibly and then closed their bathroom door and exited their bedroom. R2 then proceeded to continue to walk throughout the memory care unit.

LPA attempted to interview R3. R3 was unable to answer qualifying questions. R3 stated "a lot was going on that night." LPA asked R3 if they recalled R2 pushing R1. R3 stated that they could not remember what happened.

LPA interviewed Outside Source (OS) who stated that they were out of town when the incident occurred and they were advised by the facility that R1 was pushed by R2 causing R1 to fall on the ground. OS stated that the facility informed them that they were keeping R2 away from R1. OS stated that they believed this was an isolated incident and that R1 should remain at the facility.

LPA Interviewed Staff 1 (S1) who stated that they did not work on the date of the incident but they did work the following day. S1 stated that they read in the internal facility report that R1 was pushed to the ground by R2 and was sent to the hospital. S1 stated that R2 had a history of both verbal and physical aggression. S1 stated that R2 was physically aggressive with another resident but could not remember who or when exactly it occurred.