Complaint Investigation Report

R1’s physician’s report and care plan indicated that R1 was diagnosed with dementia and required assistance with activities of daily living and medication management. In addition, records disclosed that R1 was not conserved. During the course of the investigation, on March 17, 2021, the Department was notified that R1 was discharged from the facility and living at private home under the care of a family member. On April 21, 2021, an attempted interview with R1 was unsuccessful. Interviews with facility staff and the Administrator indicated that they had no knowledge or indication of any resident being kept at the facility against their will. Attempted interviews with other residents were unsuccessful due to their cognitive limitations. There was no corroborating evidence from outside source interviews to support the allegation.

It was also alleged that facility staff did not obtain medical care for R1 when they complained of pain. Review of facility case notes for R1 disclosed that on March 4, 2021, during lunch while sitting in the dining room table, R1 became agitated and tried to move away from the table and hit their wrist and sustained a skin tear on their right elbow. Facility staff cleansed and bandaged the area and evaluated R1 for full range of motion and R1 was able to move arm and wrist with no pain. In addition, facility staff reported incident to facility management and to R1’s responsible party. Interviews with staff who witnessed the incident corroborated the notes in the daily log. Based on the assessment completed by facility staff it was determined that no further medical attention was warranted as they continued to monitor R1’s condition throughout the day following the incident. Staff stated that they observed R1 to be calm, showing no symptoms of pain when moving arms and hands and that R1 was able to eat their dinner with no pain. Interview with outside sources confirmed knowledge of the incident. On March 5, 2021, a visitor called the police to report suspected physical abuse because they had observed a bruise on R1’s wrist and a skin tear on R1’s elbow. Law enforcement responded to the call and interviewed R1 and their visitor as well as the facility staff that were present during the incident including the Administrator. Interviews indicated R1 had sustained the injury the day before during a dining room incident. The investigation obtained corroborating evidence from the National City Police Department incident report which stated, “incident was unfounded”.