Complaint Investigation Report

On June 28, 2024, LPA interviewed Administrator (ADM) Pam Sloan, who stated that on June 18, 2024, staff noticed Resident R1 wearing a sweatshirt despite warm weather. Although staff suggested removing the sweatshirt, R1 refused, but reported feeling fine. Later, after an activity, R1 removed the sweatshirt, revealing a bruise on their left arm and side.

According to the ADM, staff notified her immediately, and she returned to the facility to assess R1. When questioned, R1 initially stated he/she injured themselves lifting the mattress, then revised the story to a bedroom fall, and finally to a bathroom fall. As R1 could not consistently explain the injury, the facility decided to send him/her to the hospital. R1 initially refused due to a family appointment but agreed after being offered a fast-food visit post-hospital. R1 was transported to the hospital around 1:30 PM and was discharged approximately 8:30 PM the same day.

ADM stated based on her internal investigation, R1 had fall in the bathroom. Three staff members were on duty during the night shift of June 17, 2024, and R1 did go to bathroom in the NOC shift. ADM stated R1 is able to use toilet by his/herself and has the right of privacy when using the restroom. ADM stated R1 did not report any incident on 6/17/2024 and 6/18/2024. ADM stated R1 did not report any incident on June 17–18, 2024, nor were any allegations of abuse received. ADM noted R1 has a history of fabricating stories.

On June 28, 2024, LPA interviewed 6 staff. 6 out of 6 staff stated they don't know what was the exact cause of R1's injuries and they did not see or hear any one physically abuse R1.

LPA interviewed 4 residents (R1 - R4). 3 out of 4 residents were unable to communicate or provide responses to questions posed by LPA. R1 confirmed no one hit him/her and that staff treated him/her well. R1 initially said he/she fell in the bedroom, then changed to a bathroom fall but could not recall date or time.

LPA interviewed R1's family member (FM). FM stated he/she does not know the exact cause of R1's injuries. FM stated he/she does not believe the facility staff abused R1. FM stated based on the conversation with the facility staff, he/she believes R1 had fall in the restroom.