Complaint Investigation Report

Allegation: Staff did not administer medication to a resident in care. It is alleged that the facility staff was supposed to administer medication to the resident to prevent the potassium levels from being high and the facility did not administer the medication. During initial visit, LPA reviewed a random sample of medications of five (5) residents and all medications are given as prescribed. During the initial visit, LPA interviewed four (4) out of four (4) staff that help administer and they all denied the allegation. During the initial visit, LPA interviewed five (5) out of five (5) residents that receive medication management care all claim to receive all medication as prescribed from the staff. During the initial visit, LPA reviewed R1's medications, Doctor’s Prescription Request, and Medication Administration Record, all medications are given as prescribed. There is not enough evidence to substantiate.

Allegation: Staff caused an injury to a resident in care. It is alleged that the staff banged the resident’s leg causing a bruise and noticed that the resident was in pain and that the leg was discolored. During the initial visit, LPA interviewed nine (9) out of nine (9) staff and they all denied the allegations and eight (8) out of eight (8) residents interviewed all said they have not experienced an injury due to staff nor witness any staff injure staff. Based on W1 interviewed, it was noted that R1’s injury on his leg was not caused by staff but due to declining health. Staff stated on being trained on elder abuse prevention and safe bed transfers. Based on record review, LPA obtained documents on staff training for preventing elder abuse, safe bed transfers, and preventing body injury. There is not enough evidence to substantiate.

Allegation: Staff did not seek medical attention in a timely manner for a resident in care. It is alleged that that the resident had been complaining of pain since 5 PM that day and that staff gave the resident Tylenol and was not transported to the hospital until 2 AM. Two (2) out of nine (9) staff interviewed was present on the date of the incident and work closely with R1 and kept in contact with R1’s primary family contact throughout the day. Two (2) of nine (9) staff interviewed stated that R1’s vital signs were normal and R1 did not complain of any leg pain on 10/31/2024 to 11/01/2024. However, at 2am, R1’s body temperature was measured at 101.7 degrees F and R1 complained of body pain so the staff immediately contacted R1’s primary contact and contacted the paramedics which transferred R1 to the hospital. Since the staff followed protocols of monitoring the R1 throughout the day, checking his vitals and body temperature, and providing medications when needed, there is not enough evidence to substantiate.