Complaint Investigation Report

The investigation revealed the following: Regarding the Allegation: Resident developed a stage 3 pressure injury while in care. It is being alleged that R1 developed a prohibited health condition while in care. During the investigation LPA Calderon observed the hospice nurse providing hospice care to R1. Record reviews indicate the following. Based on the facility’s records assisted living 24-hour report (dated 05/28/2024), noted hospice services provided to R1. R1’s hospice plan of care dated 09/23/2023 indicate that R1 was diagnosed with end stage disease, and R1 had risk for skin breakdown due to end stage disease process. R1’s hospice care plan dated 12/27/2023 indicated plans for wound care interventions were developed to address R1’s stage 3 pressure injury. Interviews conducted indicates the following: 5 out of 5 staff did not agree with the allegation. R1 could not answer any questions due to health issues. 5 out of 6 residents indicate that residents have not developed a pressure injury while in care. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “resident developed a stage 3 pressure injury while in care” is found to be UNSUBSTANTIATED.

Regarding the Allegation: Staff are not following residents’ doctors’ medication orders. It is being alleged that the facility administered medications at higher dosage compared to doctors’ orders. LPA Calderon inspected the facility with S1 and noted staff using electronic MAR when giving prescribed medications to residents in care. LPA Calderon entered the Med Tech room and noted staff using the electronic MAR system and getting ready to pass out prescribed medications to residents in care. Med Tech staff explained the medication process using the electronic MAR system and indicate that it is very hard for a medication error to be made by staff using the electronic MAR system. Facility staff indicate that when medication is given to a resident the MAR system advises staff what medication is prescribed and the dosage amount. LPA Calderon reviewed the Medication Administration Record (MAR) for R1 and R6 dated 03/2024 to April 2024, no medication errors were noted. 5 out of 5 staff denied the allegation. R1 could not answer any questions due to health issues. 5 out of 6 residents indicates that there are no issues with staff following doctor medication orders. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are not following residents’ doctors’ medication orders” is found to be UNSUBSTANTIATED.