Regarding the allegation: Due to a lack of supervision resident(s) sustained unexplained injuries while in care

The allegation of "Resident sustained unexplained injuries" alleges that resident #1 (R1) was observed with bruising to the left upper arm of which staff stated was due to the R1 entering resident #2 (R2)’s room and sustaining a fall. A photo confirmed R1’s bruise to their upper left arm. Document review confirmed R2 to have sustained a skin tear to their left arm. The LPA interviewed the administrator and health services director. Both stated that while both residents were found on the floor there was no indication of an altercation. Administrator indicated that when motion detectors went off in R2’s room, staff immediately responded. The LPA attempted to interview R1 but was unable to due to R1's cognitive impairment. Interview with responsible party (RP) revealed that they were notified that the resident had sustained an injury however was not fully informed of how injuries were sustained. Injuries sustained by R1 and R2 were reported however, injuries to R1 and R2 were un-witnessed. Medical record review revealed that staff indicated that R1 entered R2’s room resulting in an altercation which is contradictory from statements made by the Administrator and Health Services Director. Document review revealed that R1 is a known to wanderer within the secured common areas which required no additional staff supervision. However, R1 is also a fall risk which requires staff observation to promote safely. Interviews did not reveal that R1 was ambulating without supervision or that there was insufficient staffing. R2 document review revealed that they prefer to be alone and chooses not to socialize during meals and activities which required minimal staff to observe behavior. At the time of the incident there were sufficient staff on shift to ensure resident safety. At this time there is insufficient evidence to support how the injuries occurred and if R1 sustained unexplained injuries due to neglect or lack of supervision. Therefore, the allegation of “Due to lack of supervision resident(s) sustained unexplained injuries while in care" is found to be Unsubstantiated at this time.

***Continued on LIC 9099-C***

The allegation of "Resident engaged in physical altercation with other resident(s) while in care" alleges that resident #1 (R1) was in a physical altercation with resident #2 (R2) resulting in injuries. A photo confirmed R1’s bruise to their upper left arm. Document review confirmed R2 to have sustained a skin tear to their left arm. However neither injury was confirmed to have been the result of an altercation. The LPA interviewed the administrator and health services director. Both stated that while both residents were found on the floor there was no indication of an altercation. Administrator indicated that when motion detectors went off in R2’s room, staff immediately responded. The LPA attempted to interview R1 but was unable to due to R1's cognitive impairment. Interview with responsible party (RP) revealed that they were notified that the resident had sustained an injury however was not fully informed of how injuries were sustained. Injuries sustained by R1 and R2 were reported however, injuries to R1 and R2 were unwitnessed. Medical record review revealed that R1 entered R2’s room resulting in an altercation which is contradictory from statements made by the Administrator and Health Services Director. Document review revealed that R1 is a known to wanderer within the secured common areas which required no additional staff supervision. However, R1 is also a fall risk which requires staff observation to promote safely. Information gathered did not confirm that injuries sustained by either resident resulted from an altercation. At the time of the incident there were sufficient staff on shift to ensure resident safety. While this may or may not have happened there is insufficient evidence to support how the injuries occurred and if R1 engaged in “a physical altercation with another resident”. Therefore, the allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.