Complaint Investigation Report

It was alleged that on 11/28/2023, R1’s responsible party found a bruise on R1’s arm and the staff was unable to explain how it happened.

The review of the photograph shows a purple and reddish discoloration measuring approximately 3-4 inched (linear) on the right forearm.

On 11/28/2023, R1’s responsible party notified the facility staff via email regarding the observation of a long bruise on R1’s arm. Based on the email, R1 denied any pain and did not recall how it happened. It was stated they were thinking it could have happened at the exiting doorways or when R1 moved in and out of the dining table. R1’s responsible party advised staff to be extra careful when maneuvering R1 in the wheelchair since R1 is on a certain medication.

On 11/29/2023, the facility staff (S3) replied stating that S3 was with R1 and did not notice any bruising on R1’s arm. It was stated that the care staff put lotion on R1 and did not notice the bruising the last two days either. It was stated that S3 checked in on R1 that morning and seemed to be okay with no complaints of pain. S3 states to believe the bruise was from the wheelchair because R1 rests and puts pressure on the arm rest.

10 staff members were interviewed. S6 states to have seen the bruise but was unsure on how R1 sustained the bruise. S6 states to not have noticed the bruise because R1 was wearing a long sleeve that day and that he/she only changes R1 into pajamas when R1’s responsible party arrives. S6 noticed the bruise when changing R1’s clothes and reported the observation to the Medtech. Staff (S4) (S5) and (S7) believed that the bruise was from R1’s wheelchair. S4 and S5 states R1’s sleeps on the wheelchair and would lean on the arm rest.

Based on record review, the facility’s noted their observations of R1 per each shift from 11/25/23 – 12/2/2023. There was no note regarding the observation of any bruising on R1’s skin prior nor incidents that may have caused the bruising prior to 11/28/2023. R1 was also receiving services from a third party and based on the records, the resident was unable to recall what happened. It was noted that the bruise was possibly from the old wheelchair. PAGE 2 OF 5.