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32 | The investigation revealed the following: Regarding Allegations- Staff handled residents in a rough manner which resulted in injuries. It is alleged on or around 8/04/2024, S1 and S5 forcibly grabbed R6 out of bed even after R6 shouted to “Stop!” and “It hurts!”. As a result of this, R6 suffered multiple bruising on their arms, legs and buttocks. Six (6) out of six (6) staff interviewed deny this allegation. Six (6) out of the six (6) residents interviewed deny this allegation. According to staff interviews, the facility was having a Hawaiian Luau and staff went to R6’s room to encourage R6 to participate in the social event. Initially R6 refused the invitation but staff again tried to encourage R6 in attending the gathering. R6 agreed and two staff attempted to lift and move R6 from their bed to a wheelchair. R6 shouted in pain and staff stooped and called for additional staff to come assist. According to S1, it took three (3) staff in total to move R6 using the bedsheet. S1 revealed R6 did not shout in pain or ask to “STOP!” while all three staff were assisting R6 from their bed to the wheelchair. S1 revealed R6 remained at the gathering for a few hours until R6 requested to go back to their room and staff assisted R6 back to their room without incident. LPA Ramirez reviewed physician progress notes for R6 dated 05/23/2024 and 08/07/2024. These notes revealed R6 suffered an injured to their arm because of an altercation with another resident. On 08/07/2024, physician progress notes and it revealed R6’s physician did not observe new bruising on R6, but did note that R6’s bruise from 05/23/2024, was still present and taking longer to heal. 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.
Staff violated residents' personal rights. It is alleged staff forcibly grab residents out of bed against their will. Six (6) out of six (6) staff interviewed deny this allegation. Six (6) out of the six (6) residents interviewed deny this allegation. During tour of facility, LPA Ramirez observed staff proving care and supervision. LPA Ramirez observed staff transporting a resident out of bed and into a wheelchair. LPA Ramirez observed staff ask the resident for permission before assisting in transporting the resident to their wheelchair. According to S1, staff are trained to redirect and encourage residents to bathe or participate in facility activities but, never to force a resident to do anything. 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.
Staff mismanaged residents' medication. It is alleged staff consume residents’ PRN medication. Six (6) out of six (6) staff interviewed deny this allegation. Six (6) out of the six (6) residents interviewed deny this allegation. LPA Ramirez reviewed Medication Administration Record (MAR) for six (6) out of six (6) residents and did not observe any discrepancies. LPA Ramirez toured the facility medications room and did not observe any noticeable discrepancies. 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.
No deficiencies were cited for this complaint investigation. Exit interview was conducted and a copy of this report was provided. |