1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | Allegation: Staff are not able to adequately care for resident due to resident needing higher level of care. It is alleged that Reflections Memory Care unit staff are are not able to meet the care needs of resident (R1) due to the resident's aggressive behaviors that are a danger to self and others. On 10/12/2023, facility staff called Pasadena Police Department because resident (R1) was exhibiting aggressive verbal and physical behaviors that escalated into the resident attempting to hit another resident and physically injuring staff (S2) by biting staff on the shoulder, kicking, and spitting on staff (S2's) face. A total of four (4) Reflections unit staff responded and assisted during the incident. Staff attempted to redirect resident (R1). However, the resident was combative and displayed aggressive behaviors that posed a danger to others. Based on staff interviews, staff stated that they are able to provide Activities of Daily Living (ADL) care to all residents residing in the Reflections unit, including resident (R1). Nonetheless, resident (R1) has behaviors that do not seem to be controlled with medications or redirection techniques. Per record review, resident (R1) has a diagnosis of Alzheimer's Disease/Dementia with behavioral changes. Reflections Care Plan (9/29/2023) has notation of aggressive behaviors and changes in medications. A total of 6 residents were interviewed, of which only one resident was able to recall the incident. The resident stated that they did not feel resident (R1) requires a higher level of care, because aggression is not atypical to Dementia diagnosis. Incident dated 10/12/2023 resulted in a WIC 5150-72 hour hold for being a danger to others. Prior, to the most recent incident resident (R1) still met admission criteria and behaviors were being managed through program services. As of today, resident (R1) remains hospitalized, and will be re-evaluated prior to discharge in order to determine if resident (R1) still meets admission criteria. There is insufficient evidence to corroborate the allegation.
Allegation: Resident assaulted other residents in care. It is alleged that on 10/12/2023, resident (R1) who resides in the Memory Care "Reflections" unit tried to physically assault resident (R2). In addition, to last week's incident resident (R1) had a previous incident (9/20/2023) in which they became verbally and physically aggressive with resident (R3). Based on interviews conducted, resident (R1) has had several altercations with staff and residents as a result of the resident's medical diagnosis, which includes behavior disturbances exhibited through physical and verbal aggression. Staff stated that the incident dated 10/12/2023 did not result in a physical assault towards resident (R2), but confirmed that during incident (9/20/2023) R1 grabbed R3 and verbally threatened the resident. Staff intervened and separated the residents. No injuries were reported. One (1) out six (6) residents interviewed confirmed the allegation. The residents interviewed did not report safety concerns or knowledge of alleged resident altercations resulting in assaults. Per staff interviews, facility staff immediately respond to incidents. Per record review and observation, there is sufficient staffing in the facility and Reflections unit. The aforementioned incidents, were not a result of lack of supervision or insufficient staffing. Resident (R1's) behaviors are consistent with their medical diagnosis.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED.
An exit interview was conducted with Kevin Taliaferro. .A copy of this report was provided. |