Complaint Investigation Report

Interview with the Health and Wellness Director (S2) indicated that R1’s pendant was removed because R1 said it was chocking R1 at night. Thus, S2 said the caregiver tied the pendant to the bedrail. S2 said R1 thought the pendant was on the end desk and R1 attempted to retrieve it resulting in a fall. S2 indicated that R1 was given a wrist pendant in response to the incident and at the request of the R1’s family. October 31, 2024 email correspondence revealed that R1 had two call buttons to return to the facility. S2 indicated that R1’s bed is on the same wall as the pull cord. CCLD Staff observed pull cords near residents’ bed and in the bathroom. Six out of six staff interviews indicated they do not remove residents’ pendants. Five out of nine resident interviews indicated that staff have not removed their pendants. Four out of nine residents said they do not have a pendant.

Regarding the allegation “Staff did not provide resident with a call button," based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiency was cited for this allegation.

Regarding the allegation "Staff did not ensure that resident was hydrated,” it is being alleged Resident #1 (R1) had to go to the hospital due to dehydration because staff did not ensure R1 remained hydrated. Preplacement and Service Plan revealed R1 does not require assistance with meal consumption as of June 2024. Six out of six staff interviews indicated they encourage residents to stay hydrated and they provide water. Record review revealed that UTI and Hydration In-Service training was provided to staff on 06/27/24. Urinary Tract Infection (UTI) In-Service training was provided to staff on 08/14/24. Four out of nine resident interviews indicated staff does not ensure they drink plenty of water. Four out of nine residents indicated staff does ensure they drink plenty of water. One out of nine residents indicated water is offered at mealtimes. Interview with the Health and Wellness Director (S2) indicated hydration is encouraged to all residents and R1; especially when R1 receives new medication. Interview with S2 indicated residents also have pitchers or water bottles in their rooms. CDSS staff observed water stations in the bistro room, the dining room, and bottled water in residents’ room.