A review of R1’s physician’s report, dated 11/09/2023, indicated R1’s primary and secondary diagnoses were listed as base of L femur fracture s/p surgery, and Dementia/ Alzheimer’s disease. History of fall, Parkinson’s disease, anxiety, depression, and other diagnoses were also listed on the physician’s report. The report indicated that R1 had mild cognitive impairment, was confused/disoriented, able to follow directions as well as communicate needs, R1 could dress and eat on their own, was able to transfer to and from bed independently and was identified as ambulatory. A review of R1’s head-to-toe assessment form for any physical change, dated 07/08/2023, and R1’s preplacement appraisal, dated 11/16/2023, did not reveal any sign of redness or purple discoloration on R1’s body. A review of R1’s admission agreement revealed that R1 was admitted to the community on 11/20/2023.

A review of R1’s medical records obtained from Providence St Joseph Medical Center, revealed that R1 was seen in the Emergency Department on 11/23/2023 due to chief complaints of chest pain and wrist injury with bruising noted to L chest and R hand and wrist. R1 was awake, alert, and oriented x 3 and in no apparent distress. R1 reported to hospital staff some chest pain starting around noon time but did not have any chest pain at the current time. No reported shortness of breath, nausea, vomiting, or diaphoresis. R1 informed hospital staff that they were struck in the left chest at their assisted living facility by staff member and then their right wrist was grabbed. A physical exam revealed R1’s chest wall, R1’s location of pain, had a large area of ecchymosis that looked approximately a week old. The physical exam also revealed there were some mild soft tissue swelling to the distal aspect of the forearm with some mild ecchymosis. Lab work indicated R1 had mild anemia. R1 was asked if they feel safe in their living/school environment, R1 denied concerns. It was noted R1 did not show signs of physical or sexual abuse, medical neglect, untreated STI’s and or torture. R1 was noted as a high fall risk based on their morse fall risk level assessment.

Report will continue on LIC9099-C, 3rd page.

A review of the self-reported Unusual Incident/Injury Report (UIR) and a Report of Suspected Dependent Adult/Elder Abuse (SOC341) report, dated 11/24/2023, documented that on 11/21/2023 around 12:00 a.m., Staff 1 (S1) knocked on R1’s room to give them their night medication. S1 introduced themselves and gave R1 medications, R1 got upset and started to yell, kicked S1 and screaming, telling S1 I don’t want to take the medications, because they did not know who S1 was. S1 stepped back because R1 would not stop hitting and kicking them. S1 left the room. At about 12:55 a.m. S1 was passing medications to the other residents when R1 came out of their room and approached S1, stating that someone came into their room and tried to give them medication. S1 told R1 it was them who went to their room for their medication. R1 said no, I don’t feel safe if someone will come to my room. A review of a UIR, dated 11/23/2023, revealed that R1 was transferred to the hospital on 11/23/2023 due to chest pain and shortness of breath.

The LPA obtained (3) photos, that were reported to be of R1, however the face is not shown in any of the photos. Photo #1 appears to be a person sitting down who is holding their shirt down and showing their chest, the chest has purple discoloration. Photo #1 has a time stamp of 11/21/2023 at 10:14 a.m.. Photo #2 appears to be the same person holding their right hand up with what appears to be a closed fist, there is two round spots where the skin is purple. Photo #2 has a time stamp of 11/21/2023 at 10:14 a.m. Photo #3 appears to be a person’s chest, with their hands holding their shirt down, the chest has dark purple discoloration. Photo #3 has a time stamp of 11/22/2023 at 3:21 p.m.

During the investigation, the LPA conducted interviews with various residents and staff. All staff and residents interviewed revealed that they did not witness any incident between R1 and S1. Five (5) out of five (5) residents interviewed revealed that staff have never been abusive towards them, and they have never seen any staff be abusive towards other residents. All residents interviewed also revealed that they have never been forced to take medications.

Report will continue on LIC9099-C, 4th page.

Interviews conducted with Rafael Silva, who was the Interim Administrator at the time of the incident in 2023, revealed that the morning of the incident between S1 and R1, approximately around 8:00/8:30 a.m., R1’s daughter voiced concerns to him that R1 had told them that staff had attacked them. According to Mr. Silva, R1 was assessed in his office by him, with R1’s daughter present, and he does not recall observing any bruises on R1’s chest or arms. The community conducted an internal investigation and submitted a UIR and SOC341 to the Department. As part of their investigation, Mr. Silva watched the camera footage of the hallways from the night of the incident and revealed that he saw a friendly interaction between R1 and S1 in the hallway after the incident in R1’s room; saw them hugging and laughing and pointing at R1’s room. S1 documented their account of the incident. Furthermore, Mr. Silva revealed that there were no witnesses to the incident and their investigation did not reveal any sign of abuse. Both Mr. Silva and the Assistant Administrator (AA) revealed that S1 has not been involved in any other incident and is well liked by the residents. The Assistant Administrator further revealed that in S1’s seven (7) years at the community no other resident had complained about them, and that “all of the residents loved S1”. The AA also revealed that R1 did not return to the community after their visit to the hospital on 11/23/2023. Interview conducted with current Administrator David Aguiniga revealed that prior to admission, they conducted a head-to-toe assessment for R1 on 08/08/2023, at R1’s skilled nursing facility and they did not observe any cuts, wounds, or redness on R1’s body or anything unusual. Although R1 was not admitted to the facility until 11/20/2023. Mr. Aguiniga stated they did not conduct a subsequent head-to-toes assessment again prior to R1’s admission. Report will continue on LIC9099-C, 5th page.

Exit interview conducted, copy of this report issued.