Complaint Investigation Report

LPA confirmed through interview and record review that R1 was admitted to the facility above on 08/29/2024 and discharged by their responsible party on 09/19/2024. LPA requested and received Documented Narrative Charting by the facility for R1 while in care. On 09/19/2024, staff documented that R1 was involved in an altercation with another resident. According to facility staff, R1 was struck by another resident in the face which caused R1 to begin bleeding. Facility staff documented that an incident report was completed, but the Licensing Agency has not received any unusual incident/injury report (UIR) regarding R1 while in care. Through interview with LPA, it was stated that the responsible party of R1 visited the facility in September 2024 and observed R1 outside in the courtyard area of the facility wearing little clothing and shivering due to the cold. Staff documented in facility narrative charting that upon admission on 08/29/2024 R1 was an elopement/wandering risk. The Needs and Services Plan for R1 states the need for standby assistance from staff due to R1 being a falling risk and that R1 needs secure memory care due to a history of wandering and exit seeking behavior. Staff found R1 sleeping in another resident’s room on multiple occasions including 08/29/2024 and 08/31/2024. Staff also stated that on 09/10/2024, R1 needed to be redirected multiple times to leave another resident’s room after staff were notified by another resident that R1 was in their room. According to facility staff and narrative charting, on 09/16/2024, R1 had an unwitnessed fall while attempting to use the restroom alone. The Licensing Agency did not receive any unusual incident/injury report (UIR) for R1 while in care including the unwitnessed fall incident on 09/16/2024, nor the physical assault by another resident on 09/19/2024. Facility documentation states the need for R1 to have enhanced supervision due to being a falling risk as well as an elopement/wandering risk. However, multiple incidents involving R1 occurred in the facility which would not have happened with appropriate supervision by staff.

Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated.

Exit interview conducted. Copy of this report provided to facility.