Complaint Investigation Report

On the allegations, “Resident was left in an unkempt room overnight and Resident had access to an item that could pose a danger,”; it is the concern of the reporting party (RP) that on 10/15/2024, Resident 1 (R1) in Memory Care was able to get a hold of a fire extinguisher, pulled the pin, and made a mess all over their room with the fire extinguisher powder. RP further reported that they did not know if the powder was toxic, and R1 was left in their room with all the powder overnight until it was cleaned on 10/16/2024. Lastly, the RP reported that R1 grabbed the fire extinguisher again and staff keep leaving it accessible.

Interviews conducted with staff revealed that six (6) out of nine (9) staff had knowledge of R1’s incident with the fire extinguisher. Staff 1 (S1) revealed that they do not remember the exact date but does recall that a few months ago while working their NOC shift, during their second rounds of checking on the residents between 1:00 a.m. and 3:00 a.m. they found that R1 had taken a fire extinguisher to their room and sprayed the whole room. They did not know if was dangerous to inhale and the MedTech present called the Memory Care Director (MCD) and advised them of the incident. The MCD called them back and informed them that they had spoken to the Director of Maintenance and was told that it was okay to leave R1 in the room. S1 revealed that R1 was then left in their room. When asked regarding who and when was the room cleaned, they responded that they put a work order for the next day and the room was cleaned until the next day by the maintenance staff or the housekeeper. Staff 2 (S2) revealed that they were informed of the incident the morning of the incident, went to clean the room, observed the resident in the room, the powder was all over the room, and they cleaned it with a vacuum. Staff 3 (S3) revealed that after S2 cleaned the room they went and cleaned the stains on the carpet. Furthermore, staff revealed that grabbing the fire extinguisher was a known behavior of R1, staff re-direct R1 anytime he grabs a fire extinguisher, and the fire extinguishers are accessible to the residents. On 12/17/2024, the LPA observed the fire extinguishers stored in unlocked, white fire extinguisher cabinets with a glass cover, accessible to the residents in care.