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32 | Investigation revealed the following: Regarding allegation, Staff did not prevent resident from harming another resident in care, it is alleged that on 06/21/2024 staff at the facility saw R2 twisting R1's arm which resulted in R1 sustaining a fracture and dislocation to their left elbow. Interview with Assistant Administrator revealed that R1 did sustain a fracture and dislocation to their left elbow which was caused by R2. She stated that R2 wanders and constantly touches things but has never hurt anyone. She stated that staff redirect R2 and any other resident when they are wandering. She stated that R1 and R2 are both non verbal and staff (S2) was assisting another resident when the incident happened. Interview conducted with S2 revealed that they were finishing assisting another resident when the incident occurred but they saw when R2 came close to R1, lifted their blanket, grabbed their arm and immediately called out for assistance in redirecting R2. S1 immediately came to redirect R2 but R2 had already walked away and S1 then proceeded to request assistance from S3 to examine R1's arm. S1-3 stated that the incident happened in a matter of seconds and R2 was immediately redirected but that R2 was also unaware of the harm they caused to R1 due to resident being diagnosed with Major Neurocognitive Disorder. 5 out of 5 staff interviewed denied the allegation and stated that there are enough staff on schedule to properly supervise and care for the residents. 8 out of 8 residents interviewed were unable to corroborate the allegation. They stated that they are satisfied with the services, staff protect them from harm and do not have any concerns. LPA reviewed R1-2's Physician's Report for Residential Care Facilities for the Elderly (RCFE) which revealed that R1-2 are diagnosed with Major Neurocognitive Disorder and have conditions and behaviors in relation to that diagnosis. R2 has wandering behavior and R1 is not able to feed self and is nonambulatory.
During the time of the visit, LPA did not observe any altercations between residents and observed that there were enough staff on schedule. LPA additionally observed staff tending to residents and redirecting residents which were exhibiting wandering behavior. LPA reviewed documents and observed that the proper reporting was done by facility staff as well as proper follow up calls made to both involved resident's responsible parties. LPA additionally reviewed Facility Personnel Report (LIC500) which revealed that the facility is properly staffed to oversee and care for the residents in placement. Based on statements gathered from interviews conducted with staff, residents, LPA record review and observations there was not enough supportive evidence to concur with the reported allegation.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Exit interview held. A copy of the report was provided to Assistant Administrator Lori Lackey. |