Complaint Investigation Report

Lack of supervision resulted in Resident on Resident Altercation:

The allegation is that facility staff lack of supervision resulting in on 4/10/2024 around 3:30PM, a resident R1 wandering into another resident R2's room and having alteration between R1 and R2. Both R1 and R2 live in the memory care unit.

On 4/19/2024, LPA interviewed Executive Director (ED) Joyce Welch. ED stated on 4/10/2024, resident R1 entered resident R2's room. R1 has neurocognitive impairment and thought that is R1's room. R2 asked R1 to leave the room and R1 got mad. R2 has a private companion (PC1) at that time. PC1 stated R2 told PC1 that R1 attacked R2 but PC1 stated he/she did not observe it.

LPA interviewed PC1. PC1 stated he/she was in the restroom when the incident occurred. PC1 stated he/she did not see R1 attacked R2 but he/she saw R1 in R2's room when he/she exited from the restroom. PC1 stated he/she asked R1 to leave R2's room.

LPA interviewed resident R2. R2 has neurocognitive impairment. R2 stated he/she cannot recall the incident. R2 stated the facility has a good environment to live. R2 stated he/she likes the facility.

LPA interviewed Wellness Director (S1). S1 stated R2 has private companion from 6:00AM to 6:00PM Monday to Saturday. S1 stated on 4/10/2024, he/she received a report that resident R1 entered resident R2's room and R1 and R2 had altercation. S1 stated he/she went to R2's room immediately and R1 already left R2's room. S1 assessed R2 immediately. S1 stated he/she did not find any injury on R2, and R2 stated he/she is fine. S1 stated he/she notified Police, Ombudsman, CCL office and resident families immediately. S1 stated after the incident, the facility provided a week's staff training to prevent the similar incident to occur.

R1 moved in the facility on 4/2/2024. R1 did not have similar incident before during 9 day's stay in the facility.

Based on the review of R1's Pre-Admission evaluation document dated 3/17/2024, R1 has neurocognitive impairment, elopement, exit seeking/wandering and needing occasional intervention.

Based on the review of the LAW Enforcement Task Report, the R2 had no visible injuries. and this is the R1's first incident.