Complaint Investigation Report

Staff did not provide adequate care and supervision to a resident

Interview with W1 revealed S2 and S3 are older and fragile and can’t provide physical care for R1, it’s difficult for S2 and S3 to handle R1 without assistance. Interviews with S2 and S3 revealed R1 was difficult to work with when R1 first arrive to facility, when R1 didn’t have medication to help with behaviors. Now that R1 is on medication, R1 is much easier to work with. Interview with S1 revealed facility is in the process of hiring more staff, which will allow more supervision of residents in care.

Record review revealed, staff received 20hrs of training in dementia care, postural support, restricted health conditions, hospice care, and medication administration. Record review and interviews with S2, and S3 revealed, staff have not received training related to residents’ behavioral challenges

Staff are inappropriately restraining a resident

Interviews with W1 revealed facility is keeping R1 restraint to keep R1 in the wheelchair. Interview with S1 revealed there was no physician order for the wheelchair belt, the facility was given permission from R1’s children to place a belt on the wheelchair to prevent R1 from sliding out and possibly falling on the floor.