Complaint Investigation Report

The investigation revealed the following: Regarding the allegation "Facility failed to meet the reporting requirements” it is being alleged that the facility failed to submit incident reports to the Licensing Department. Staff Interviews and Records reviews indicate the following: hospital and facility records indicate that C1 was taken to the hospital on 12/15/2023 after a fall incident and was also taken to the hospital on 01/15/2024 for a scheduled surgery. Staff S1 and S4 verified that both incidents occurred. Record reviews of facility records did not indicate evidence of when and how the incidents were submitted to the Licensing Department. Record reviews of the Departments records conducted on 01/18/2024 and 01/25/2024 did not indicate receipt of reports regarding the said incidents. Regarding the allegation “Facility failed to meet the reporting requirements,” the preponderance of the evidence standard has been met therefore the allegation is substantiated.

An exit interview was conducted and plans of correction were developed. A copy of this report was provided to Area Director.