Complaint Investigation Report

The investigation revealed the following:

In regards to the allegation: " Facility staff did not assist resident with obtaining a prescription ." , it is alleged that the facility staff was informed of the need for antibiotics for C1 on 11/13/2023, but had not assisted resident with obtaining antibiotics, until 11/15/2023 when staff took C1 to the emergency room. Staff interviewed denied the allegation. Staff interviews revealed that on 11/13/2023, C1 received a scheduled check-up by her Nurse while at the Day Program. C1 gets checked-up by her Nurse on a regular basis, 3x a week. C1’s nurse took photos of C1’s wounds and sent a text message to the facility staff to ask the staff to send the photos to C1’s PCP and possibly get antibiotics. On the same day, 11/13/2023, S1 sent the photos to C1’s PCP and wound care Nurse. S1 stated that she did not get a response from the wound care nurse until 11/14/2023 and asked for a detailed description of the wound, but no antibiotics were prescribed. On 11/15/2023, C1’s PCP nurse contacted S1 and was instructed to take C1 to the ER, but no antibiotics were prescribed. The facility staff immediately followed C1’s PCP’s instruction and took C1 to the Emergency room the same day. Staff members interviewed also stated that the facility has in-house nurses who assist in obtaining prescriptions for the clients. Client interviewed could not corroborate the allegation and stated that staff assist in obtaining prescriptions every time. Therefore, there was insufficient evidence to corroborate with this allegation.

In regards to the allegation: " Facility staff did not observe a change in the resident's condition ", it is alleged that on 11/09/2023, C1 has a wound that was about the size of a finger nail and was seen by the Physician on 11/10/2023. On 11/13/2023, The wound had grown larger and was infected and on 11/15/2023, the wound had grown to the size of a credit card. Interviewed staff members denied the allegation and indicated they always monitor C1’s condition as they are all aware of her skin picking disorder. Staff members stated that C1 has a chronic skin picking behavior. Staff indicated that they always redirect C1 whenever they see that she is starting to scratch or pick her skin. Staff indicated that this has been an ongoing issue with C1 since she was admitted in the facility in 2021. Staff members stated that the facility’s in-house nurses administer wound treatment to C1 daily. Staff stated that all staff on-duty conduct their rounds to monitor any changes to the clients condition. Staff also stated that they keep C1’s wound clean every day to avoid infection. Interviewed client cannot corroborate the allegation and stated that staff take good care of her and other clients in the facility. LPA reviewed files and documentation which showed that C1's doctor's visit on 11/10/2013 indicated that her wound has improved. The documentation reviewed also showed that the staff monitored and treated C1’s wound daily. Additionally, staff conducted rounds to check on clients on a regular basis. Therefore, there was insufficient evidence to corroborate with this allegation.