Complaint Investigation Report

On the allegation that facility staff caused an injury to a resident while in care, it is the Reporting Party’s (RP) concern that R1 reported to the RP that on July 15, 2023, Staff #1 (S1) kicked R1 on the foot, causing a bruise on R1’s foot. LPA Elsie Campos conducted an initial 10-day visit, and interviewed S1 about the incident. The interview revealed that R1 became agitated because R1 did not get what they wanted. At some point during the agitation period, R1 eloped the facility by exiting through the back iron gate. Prior to R1 eloping from the facility, R1 was slamming and kicking the iron gate. S1 stated that they did not see it but heard R1 slamming and kicking the gate continuously. Once R1 eloped the facility, S1 followed R1. Upon returning to the facility, R1 continued to kick the gate. S1 denied kicking R1 on the foot.

LPA Urena interviewed District Manager (DM) Joanna Iniguez about the incident. The interview revealed on July 15, 2023, R1 became aggressive after R1 was denied a cigarette. R1 requested a cigarette out of the set schedule, and when R1 was denied a cigarette, they became angry, eloped the facility and kicked a backdoor gate. The DM stated this maybe the reason for the bruise on R1’s foot. On July 23, 2024, LPA Urena conducted a telephone interview with the Quality Assurance Specialists (QA) for Tri-Counties Regional Center. The QA Specialist stated that R1 had become agitated due to not receiving a cigarette. Due to the incident that took place on July 15, 2023, the QA stated that R1 was placed on a contract to be followed by R1 to reduce the possible related emotional triggers that may come with anticipation of the cigarette and being denied the cigarette and/or running out of the cigarette. On July 25, 2023, R1 had a doctor’s appointment. Review of the medical records indicate R1 was seen by the doctor for blisters and foot sprain of the right foot. There is no mention of the bruise or care for the bruise on the discharge medical record. The LPA reviewed a picture of the bruise on the foot of R1, the bruise appears to be on the left foot, in the middle of the left lateral arch side of the foot between the bottom and the upper part of the foot. The bruise appears to be a clearly defined rectangular shape with an approximate 2” width and 1” height. R1 stated to the RP that S1 had kicked R1, however the RP did not specify where S1 kicked R1. The LPA was unable to interview R1 as they no longer live at the facility or the Administrator as they are no longer employed at the facility.