Complaint Investigation Report

Staff do not maintain adequate records for resident.

The investigation revealed the following: Regarding the allegation "Staff do not maintain adequate records for resident,” it is being alleged that Resident #1 (R1) MD orders and special diet were not available for review, April MARs were not on site, blood sugar readings are recorded on a “Blood Pressure Log”, unnecessary items are listed on MAR, staff are merely checking off the days/times for medications being administered vs putting their initials, there are no staff signatures on MAR, and PRN medication (albuterol and diclofenac cream) does not indicate the reason as to why it was given for as should be noted on reverse side of MAR. Record review reveals that R1’s doctor’s visits on 03/25/24 and 04/30/24 (for a physical exam) was on file but it did not contain special diet information. Interview with the House Manager indicated that R1’s doctor does not like to complete the Physician’s Report (LIC 602). Record review reveals that May MAR, Blood Pressure Log with blood sugar readings as of 05/01/24, and Blood Sugar Log as of 05/21/2024 was on site. Interview with the House Manager indicated that a report is completed and previous MARs are sent to the main office and as of 05/22/24 3:20 PM, the office was closed. Interview with the House Manager also indicated that the facility ran out of Blood Sugar Logs and used the Blood Pressure Log as a temporary replacement. Record review reveals that MAR is checked off and staffs’ initials are listed on the back of the MAR; however, the charting instructions on the document is not followed. In addition, the MAR does not include the reason as to why the PRN medications were given. Regarding the allegation “Staff do not maintain adequate records for resident,” based on record reviews, interview(s), and observation the preponderance of evidence has been met therefore the allegation is Substantiated.

An exit interview was conducted and plans of correction developed. A copy of this report and appeals rights was reviewed and left with House Manager Uila Sekona .