Complaint Investigation Report

It was reported that the client has been refusing medications at times. Facility staff attempt to administer medication up to three (3) times, and if the client continues to refuse, they discontinue further attempts. Concern was raised that Resident 1 (R1) may not be receiving prescribed medications, including PRNs, on a consistent schedule. On 01/10/2025, LPA conducted an interview with the Wellness Director (WD), who stated that R1 occasionally refuses medication and that, per policy, staff make three (3) attempts and notify R1’s physician and family of refusals. Additional interviews with the Executive Director (ED) and two (2) MedTechs on 09/30/2025 confirmed that staff follow the facility’s medication policy and procedures when a resident refuses medication. LPA reviewed R1’s Centrally Stored Medication Record (CSMR) and Medication Administration Record (MAR), which showed refusals were accurately documented and that notifications to R1’s physician and family were made. Facility medication policy specifies that staff are trained to make multiple attempts and record all refusals. R1 was also interviewed and confirmed that staff consistently offer medications multiple times before documenting refusals.

Based on interviews, record review, and policy examination, there is insufficient evidence to support the allegation that staff mismanaged R1’s medication. Documentation shows staff followed policy and communicated refusals appropriately. Therefore, the allegation is deemed unsubstantiated at this time.

Staff did not ensure resident was kept clean

It was reported that Resident 1 (R1) was not being properly cleaned during incontinence care, with fecal matter observed on their person. To investigate, LPA conducted interviews and reviewed facility records.

Interview with WD denied the allegation, stating that residents, including R1, are checked every two (2) hours or as needed for incontinence care. WD further reported that R1 occasionally refuses care. Furthermore, LPA observed that the facility internal notes documented R1 refused incontinence care on 12/21/2024 at 6:40 AM and again at 3:00 PM. Moreover, during the initial visit, R1 was observed to be clean, well-groomed, and free of odor. R1 reported that their incontinence needs are met and that they had no concerns. R1’s Physician’s Report confirmed R1 is incontinent but able to communicate needs. Lastly, All other residents interviewed confirmed they receive proper incontinence care and are changed as needed. Therefore, based on interviews, observations, and record review, there is insufficient evidence to support the allegation. Therefore, the allegation that staff did not ensure R1 was kept clean is deemed Unsubstantiated at this time.