Complaint Investigation Report

Allegation: Staff did not follow medical professional's prescribed orders

On 11/14/2024, the Department interviewed S1. S1 stated that R1 continually removed the medically ordered CPAP mask. The Department reviewed Medical Administration Records (MAR) from 01/2023 thru 03/2023 with prescribed medication orders (John Muir) from 10/27/2022 and observed not to be administered consistently. R1 was prescribed continuous positive airway pressure (CPAP) for obstructive sleep apnea in 2019. Doctor’s order prescribes to wear CPAP mask nightly and utilize distilled water. Records (ResMed) shows that no data was available during the months of Dec 2022-Jan 2023 which indicates CPAP machine was not in use. Further review of MAR and medication orders (10/27/22) there was no use of ketoconazole 2% shampoo for scalp, donepezil 23mg Tab was not administered according to February ’23 MAR and latanoprost .005% for glaucoma was not administered according to March ’23 MAR.

Allegation: Staff isolated resident in care

On 10/11/20204 the Department interviewed W1. W1 stated that the staff isolated R1 to their room W1 stated that R1 developed a dementia related behavior of spitting inside. W1 stated that R1 was isolated and sat in her room alone all day, R1 ate her meals alone.

On 10/03/2024 the Department interviewed S2 and S3. S2 stated that R1 wasn't isolated. R1 would stay in their room the first year because daughter brought DVD's and R1 would watch movies.