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32 | The investigation revealed the following:
Regarding the allegation, Staff is physically abusing resident, it was reported that on December 30, 2025, R1 notified Witness 1 (W1) that a male staff member attacked R1 resulting in R1 sustaining red marks on their forearm. During the investigation, LPA did not observe any bruising on R1’s forearm. LPA was unable to qualify R1 due to their diagnosis. When interviewed, W1 stated they visited R1 on three different occasions and was unsure if the incident actually occurred as the resident has often had mood swings where they were observed upset with staff and crying. Then, moments later, telling the same the same staff that they love them in a happy tone. LPA interviewed Witness 2 (W2) who stated they have been providing care for R1 for several months, and R1 has a long history of alleging abuse from other residents as well as from male and female staff. W2 stated R1 would sometimes gesture that someone has hit them once on the head with hammer and point to any staff present at the time. W2 stated that during their visits with R1, they always do a body and skin check from head to toe and has not observed any of the injuries described by resident. The witness stated they were not present during the visit when W1 met with the R1, however they noted that R1 was having paranoid delusions on December 26, 2025. Five out of five staff interviewed denied the allegation. Staff 1 (S1) stated sometimes R1 seems happy but will be sad five minutes later and often talks about missing family. Staff 2 (S2) stated that caregivers often try to assist R1 but the resident becomes upset and aggressive so staff does not force them. Instead, they take a break and try again at a later time, when the resident is more calm. A service plan dated June 1, 2025 indicates R1 has a history of frequent disruptive, aggressive, and socially inappropriate behaviors. Witness 3 stated they visited R1 on December 17, 2025 to provide wound care for a skin tear on R1’s arm and back but could not determine if the wounds were due to a previous fall or other event.
Based on the observations made, interviews which were conducted, and the records that were reviewed, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED.
An exit interview was conducted with Nurse and Clinical Consultant Shelley Mitchell and Interim Executive Director Kay Cano, and a copy of this report and LIC811 were provided at exit. |