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32 | Staff failed to meet residents need; resident had unexplained bruising.
It was alleged that there were instances where facility staff allegedly failed to meet the Client #1 needs as they were observed with having unexplained bruising. Regarding Client #1 (C1) is diagnosed with unsteady gait and per their physician’s report and Individual Program Plan (IPP) C1 requires constant supervision when walking to avoid falling. C1 also has a neurocognitive disorder that requires for them to wear a helmet to avoid injuries and maintain safety. An interview with a third-party witness revealed that on or about August 2021, facility staff reported C1 having a fall, resulting in a bruise to their lower back. Licensee Vasquez reported that he had assessed C1, and they were fine. However, on March 2, 2022, C1, was sent out to the hospital a couple days later for an unrelated matter. Per Licensee Vasquez C1 was sent to the hospital due to an existing chronic medical condition.
Additionally, LPA conducted a records review of the facility Nurse’s notes for clients in care dated from March 2020 through September 2021. Per the Nurse’s notes dated 03/30/2020, Client #2 (C2) was noted to have bruising to left upper ear lobe and C2 could not provide information on what happened. On Nurse’s notes dated 06/20/2020 C2 was noted to have discoloration to their right hip and posterior right thigh, C2 was not sure what happened. Nurse’s notes dated 03/09/2021 C2 was noted to have bruising and discoloration to their forearms, as well as a circular mark to their posterior left extremity, C1 was unable to state how the bruising and circular mark was sustained, as they did not provide a response when asked. Nurse’s notes dated 09/01/2021 C2 was noted to have discoloration to posterior left shoulder and left lateral midback, C2 was noted to be unable to recall what happened. Nurse’s notes dated 09/13/2021 C2 was noted to have discoloration to their left orbit and is noted to not recall what happened. Other notes reviewed revealed that there were incidences where C2 was noted to have scratches, bruising, and scabbing to their bottom lip, in these instances C2 was able to state/recall what happened. Per the Nurse’s notes reviewed revealed that there were instances where staff provided and explanation for the injuries and other times when they did not. Per an interview with the Licensee/Administrator Vasquez the bruising and other injuries were discounted as being associated or a result of when clients would have behaviors and became agitated.
Based on insufficient evidence to refute or corroborate evidence the allegation of Staff failed to meet residents need; resident had unexplained bruising is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.
An exit interview was conducted and a copy of this report, and LIC811-Confidential names list was reviewed and provided to Manuel Vasquez, Licensee/Administrator. |