Complaint Investigation Report

The second occasion involved S1 raising his/her voice at R1 when S1 found R1 on another floor of the building. R1 stated S1 used a raise voice towards R1 to ask R1 what R1 was doing and to tell R1 that R1 is not supposed to be in that part of the building alone.

LPA Marrufo obtained a copy of resident R2’s Appraisal/Needs and Services Plan (ANS). R2’s ANS states, “The resident has episodes of being verbally aggressive towards other residents,” and “Resident had an incident of physical aggression with another resident, the resident moved [his/her] walker and hit another resident on [his/her] right leg.”

LPA Marrufo obtained a copy of written statements made by staff as part of an internal investigation by the facility. The internal investigation had interviews of six staff. One of the six interviewed staff, S2, stated to have observed the incident in which R2 was having aggressive behaviors and S1 was attempting to supervise and redirect R2. S2 stated that while R2 was having aggressive behaviors, R1 was sitting in the common area. R2 stated that S1 was attempting to tell R1 to go to his/her room and that the area was not safe. S2 stated that S1 did not raise his/her voice at R1 but used a firm, but not disrespectful tone. S2 stated that S1 was encouraging R1 to go to his/her room. S2 stated that R1 continued to walk towards R2 and walked around R2.

On 11/09/2023, LPA Marrufo interviewed R1. R1 stated that R1 had an incident with a staff, but did not want to name the staff. R1 stated that a resident used his/her walker to block R1 and a staff. R1 stated the resident uses the walker “almost as a weapon.” R1 stated to have asked the resident to let him/her out and R1 was able to walk past the resident, but the resident continued to block the staff. R1 stated the staff did not say anything to R1, but R1 did not like that the staff told R1’s child that he/she was protecting R1 from the resident with the walker.

On 11/09/2023, LPA visited R2, who had a private care giver at the facility. LPA Marrufo attempted to interview R2. However, R2 appeared confused, and LPA Marrufo did not continue with the interview. LPA Marrufo interviewed R2’s private care giver, who stated that R2 does block people with R2’s walker.