Complaint Investigation Report

Staff is not providing adequate care and supervision to resident.

On the allegation that Staff is not providing adequate care and supervision to resident; it is the concern of the Reporting Party (RP) that the resident (R1) was not being monitored by staff and allowed R1 to self-harm by allowing R1 to self injure their fingers.

To investigate the allegation LPA Elsie Campos interviewed staff, and administrator on 07/05/2023. The staff’s (S1) interview revealed that R1 came back from the hospital with bite marks to their fingers, however, the bites were covered with bandages. Furthermore, S1 stated that they were attending to R1’s biting injuries by changing the bandages and keeping the wounds clean two times a day, every day. S1 stated that they called the home health nurse on June 20 th , 2023, to inform them that they had noticed that R1 had continued to self-bite their fingers. Staff’s (S2) interview revealed that after R1 came back from hospital on 06/18/2023, R1 came back with signs of biting on R1’s hands, “they didn’t look bad, so we covered R1’s palms for prevention, but then R1 started biting their fingers. We informed R1’s responsible party, and the nurse about the concern when R1 came back from the hospital. We (staff) were monitoring R1 throughout the day and night to prevent any further self-harm.

The Administrator’s interview revealed that R1 returned from the hospital after the 06/15/2023 fall with home health services. The Administrator added that staff reported right away to the Administrator when they noticed that R1 started biting their hand and fingers; furthermore, the administrator contacted R1’s responsible party and the home health nurse to inform them of the hand/finger biting. On 10/22/2024, LPA Urena spoke with the RP and interviewed them on the phone. The RP stated that when they were changing the dressings on the right hand of R1, they noticed additional self-inflicted injuries to R1’s right hand fingers and hand. LPA Urena was unable to communicate with the attending home health nurse. Home Health was being provided per hospital discharge instructions for the injury to the forehead due to the fall at the facility, and an abrasion to the hand which happened at the hospital.