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32 | During today's visit, LPA obtained the following documents: staff and resident rosters, R1’s Physician’s Orders and Hospital Discharge Notes. LPA interviewed the Executive Director, Assisted Administrator, Staff #1 (S1) to Staff #4 (S4), Resident #2 (R2) to Resident #6 (R6). LPA obtained Staff In-Service documents.
The investigation revealed the following: in regard to the allegation, "Staff caused an injury to a resident in care." It is alleged that on 01/08/2025, R1 fell and sustained a purplish bruise on R1’s face. It is also alleged that on 03/23/2025, R1 suffered another fall and was hospitalized. LPA interviewed five (5) out of five (5) residents that denied the allegation stating that they were not injured caused by staff and did not witness any residents injured caused by staff. Four (4) out of five (5) residents also stated that they feel safe. One (1) out of five (5) residents stated feeling safe but the staff are not friendly. Four (4) out of five (5) residents stated that the staff treat them good and are well cared for. LPA interviewed Executive Director, Assistant Administrator, and four (4) out of four (4) staff that denied the allegation and stated that staff have not caused any injury to residents and have not witnessed any staff injure any residents. Executive Director, Assistant Administrator, and four (4) out of four (4) staff also stated that staff follow protocol of care for a resident by on-duty staff reporting the fall immediately to the facility LVN to assess the resident’s range of motion and contact 911 and non-emergency paramedic for the resident to be transferred to the ER. Executive Director and Assistant Administrator stated that when R1 fell on 01/08/2025 and 03/23/2025, the staff responded immediately by the staff assessing R1 and since it was an unwitnessed fall, staff contacted the paramedics and R1 was sent to the ER for further evaluation. LPA reviewed Staff In-Service training on resident fall protocols dated 08/01/2025, Personal Rights dated 05/27/2025, Meeting the Resident’s Personal Needs dated 04/29/2025, and Elder Abuse Training dated 01/06/2025. There is not enough evidence to substantiate.
Based on statements and interviews conducted with staff, residents, review of client files and facility file records, 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 allegations are UNSUBSTANTIATED.
Exit interview was held, and a copy of this report was provided to the Executive Director, Pamela Ogot. |