Complaint Investigation Report

Allegation 2. Facility did not ensure that staff had the required training/certification(s) while working at the facility.

The LPA was able to interview the staff in question and the administrator regarding this allegation. Staff interviewed confirmed that on 8/13/22, she had a family emergency. During this time there was no LVN coverage for the home. The administrator stated that he did receive a call from the staff and was notified of the emergency and that the staff would need to leave early. Staff left the home at about 3pm but there was no LVN coverage until about 4pm. The PM shif LVN was notified and arrived at the home early. The program design outlines that there will be coverage 24 hours a day, but in this case there was no coverage available. Based on interviews with LVN staff and confirmation from the administrator, this allegation is deemed Substantiated.

Allegation 3. Staff falsified resident(s) MAR.

LPA was able to speak with the facility administrator and the LVN staff who was noted in this allegation. The LVN was interviewed at about 9:45AM, and confirmed that on 8/13/22 she had a family emergency and needed to leave the facility early. The LVN states that she was able to give the medications to 3 out of the 4 residents at the home, but would not be at the home to give the 4pm medication to the resident in question (R1). The LVN then stated that she prepared the meds and placed them in the locked medicine cabinet for another staff to give them to the resident while she was out. The LVN signed the MARS, indicating that the medications had been given out, however R1 never received the 4PM medications. The administrator also confirmed that this incident occurred and that he has held an in-service and medication training for all staff. Based on confirmation from the facility LVN and Administrator, this allegation is deemed Substantiated.

Allegation 4. Staff did not administer medication(s) to resident as prescribed

LPA was able to speak with the facility administrator and the LVN staff who was noted in this allegation. The LVN was interviewed at about 9:45AM, and confirmed that on 8/13/22 she had a family emergency and needed to leave the facility early. The LVN states that she was able to give the medications to 3 out of the 4 residents at the home, but would not be at the home to give the 4pm medication to the resident in question (R1). The LVN had prepared the medications for R1, however they were not given. The administrator confirmed that this incident had occurred and that R1 was experiencing a behavior episode. A special incident report was sent to Licensing, R1's doctor and R1's responsible party. Based on confirmation from the facility LVN and the Administrator, this allegation is deemed to be substantiated at this time.

Exit Interview conducted, deficiencies cited and report issued.