Complaint Investigation Report

Allegation: Staff did not seek medical attention to resident in a timely manner.

Staff left resident soiled for an extended period of time.

The investigation findings revealed that R1 had been living at this facility since February 28 th , 2024, and due to severe emphysema, R1 used full-time oxygen. Review of R1’s facility records revealed that R1 was able to independently get in and out of the bed (based of the Physician’s Report - dated on 02/01/24). Moreover, based on facility’s “Preplacement Appraisal Information”, dated on 02/10/24, R1 was able to independently ambulate throughout the facility and only required assistance with bathing. Interview with the Business Director and three (3) staff, revealed that all incontinent residents are scheduled to be changed every two (2) hours or as needed. Moreover, LPA was informed that the night shift is conducting round checks at least every 2 hours. However, some residents do not want to be disturbed and to be checked on at nights.

R1’s first fall incident occurred on 06/24/24 at 9:15am and the facility called 9-1-1. When the paramedics arrived, R1 was able to answer all questions and R1 refused paramedics help when asked. However, due to this incident, the facility staff was instructed to frequently check on R1 and obtain his/her vitals, (i.e. R1’s blood pressure, check for signs of injury, and monitor for any changes in the resident.) During the interview with S3, LPA was informed that on 06/25/24, S3 started their shift at 10:00pm and at around 10:10pm, while conducting their first-round check, S3 visited R1’s room and observed that R1 was already in bed. After finding out that R1 does not require any assistance, S3 wished R1 good night sleep and left the room. At around 1:30am, S3 came back to check on R1 and found R1 unresponsive on the floor. Based on the facility's “Fall Policy”, the staff can't move/relocate/touch an unconscious resident. Interview with S3 revealed that upon discovery of R1’s incident, S3 immediately contacted the MedTech (the staff are trained to immediately notify the MedTech, who then will contact 9-1-1 and wait for the Paramedics to arrive). All parties interviewed denied the above allegations and informed LPA that the staff did follow the facility's Policy and timely medical attention was provided to R1. Moreover, eleven (11) out of thirteen (13) residents interviewed expressed no concern regarding the above allegations. LPA was informed that the facility staff are well trained to provide immediate medical attention in emergency situations and all incontinent residents are always provided proper assistance timely. Although LPA was unable to interview R1, LPA conducted an interview with R1's family member, who also expressed no concerns regarding the above allegations. Based on the information obtained through interviews, there was insufficient evidence to prove that staff did not seek medical attention to resident in a timely manner and R1 was left in soil for an extended period of time. Therefore, based on interviews, and information gathered, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered