Complaint Investigation Report

Regarding allegations - Staff did not ensure resident had their oxygen when out of room and Staff did not safeguard resident's personal belongings: Information was received that Resident #1 (R1) was not on continuous oxygen from approximately 01/09/2025 – 01/17/2025. According to the reporting party the facility evacuated on 01/09/2025 due to the Kenneth fire and R1’s portable oxygen was lost. Staff did not ensure R1 was on continuous oxygen. R1 went to a hair appointment without a supply of oxygen.

It was confirmed through interviews and records review that there is an order on file from R1’s physician that R1 requires continues (24 hours) oxygen use. Staff interviewed confirmed that R1’s portable oxygen cord was lost during the evacuation period. Staff stated that R1 was provide with a concentrator which was used in room and when R1 would go down for meals. R1’s facility records reviewed with staff revealed that R1’s assessments/care plan did not indicate that R1 is required 24-hour oxygen use. Staff could not confirm that R1 was monitored and ensured that when R1 left the room or went out of the facility was with oxygen.

Based on the information obtained through record review and interviews; the allegations “Staff did not ensure resident had their oxygen when out of room and Staff did not safeguard resident's personal belongings”, is deemed substantiated at this time.