Complaint Investigation Report

LPA Monter interviewed staff S1-S8. S1 stated if R1 is agitated, will walk by himself/herself. S1 stated the care givers are there and will assist the R1 whenever R1 tries to walk. S1 stated that at night, R1 will try to get up and go to the bathroom, in his/her bedroom. S1 stated R1 will also sometimes go out of his/her room. S1 stated R1’s bed has an alarm that will notify staff if R1 gets out of bed.

S2 stated R1 has an issue with his/her knee and loses balance. S2 stated R1 needs assistance in walking. S2 stated staff will go with R1 when R1 walks. S3 stated R1 needs assistance walking. S3 stated R1 has an unsteady gait and uses a wheelchair or walker that he/she doesn’t like to use.

S4 stated R1 is unstable, so he/she assists R1 to ensure he/she doesn’t fall. S4 stated staff are supposed to watch R1 because he/she likes to try to walk by him/herself. S4 stated staff are supposed to assist R1 when he/she walks or a hand to keep R1 safe. S5 stated R1 is a rebellious resident. S5 stated R1 will listen sometimes and will not listen other times. S5 stated when he/she sees R1 walk, he/she will offer R1 the wheelchair. S6 stated R1 needs help with walking. S6 stated he/she has helped R1 walk a little. S6 stated that he/she has not had many interactions with R1.

S7 stated when R1 walks around, he/she has an unsteady gait. S7 stated R1 holds onto the side rail when walking. S7 stated staff are supposed to assist R1 if he/she gets up or tries to walk. S7 stated R1 will try to get up in the middle of the night. S7 stated R1 will be put in bed and then will get up and walk around. S7 stated the night shift needs that supervision because R1 is a fall risk and likes getting up at night. S7 stated the night alarm goes off at night. S8 stated R1 can walk, but its unsteady. S8 stated they are supposed to keep an eye on R1 because he/she likes to get up on his/her own but has an unsteady gait.

On March 7 & 13, 2025, LPA Monter interviewed staff S9-S11. S9 stated staff make sure they are watching R1 during their shift. S9 stated R1 wanders and is fall risk. S10 stated R1 was able to walk a little, but shaky and not stable. S10 stated staff was supposed to help R1 when he/she walks because he/she’s a fall risk. S11 stated he/she worked the night shift but doesn’t remember working with resident R1.