Complaint Investigation Report

Staff administered medication to resident(s) not prescribed by a physician.

The investigation revealed the following: in regards to the allegation " Staff administered medication to resident(s) not prescribed by a physician.", it is alleged that facility staff gives medication to a resident that is not prescribed by a doctor. The complaint did not provide the name of the staff member(s) administering medications not prescribed by a physician. LPA reviewed C1’s medications and observed medications to be documented properly and given as prescribed. Interviews conducted with staff members, including S1 revealed that medications are administered as per doctors’ orders. Staff members indicated that they use a tool Therap to document clients' activities, behaviors, daily notes, reminders etc. electronically for each client. Staff members also use Medication Administration Record (MAR) form to document the clients daily intake of prescription medication and over the counter (PRN) medicines. MARs record medications to be administered by schedule and correctly per doctors’ orders during each Staff member's shift . Interviews conducted with clients revealed that they are provided with their medications on schedule and as prescribed. Clients interviewed stated they have not been given any medications that were not prescribed by their doctors. Therefore, there was insufficient evidence to corroborate with this allegation.

Staff engaged in inappropriate physical contact with resident(s).

The investigation revealed the following: in regards to the allegation “Staff engaged in inappropriate physical contact with resident(s)” , interviews with staff members revealed that C1 has a behavior of putting his head on staff’s shoulder when watching tv or when staff is using iPAD so he can see better, but staff redirect him immediately. Staff interviews revealed that they did not witness or have seen any staff member engaged in inappropriate physical contact or interaction with C1. Interviews conducted with clients revealed that they have not witnessed any staff member having physical contact with them or other clients. Therefore, there was insufficient evidence to corroborate with this allegation.

Resident(s) not accorded dignity in relationships with staff.

The investigation revealed the following: in regards to the allegation " Resident(s) not accorded dignity in relationships with staff “, it is alleged that two (2) clients (C1-C2) were restricted from participating the Christmas party on-site. Staff members denied the allegation and stated that all the clients in the facility were invited to the party. However, staff members indicated that some clients opted to stay in their rooms after a while because they felt uncomfortable when around a big group of people. Staff members stated that all the clients participated at the party and no one was excluded. Interviews conducted with clients revealed that everyone was invited, and all the clients in the facility ate and joined the party. There is no evidence that would conclude that the clients are not accorded dignity in relationships with staff. Therefore, based on interviews conducted and documents gathered, LPA has determined that this allegation is deemed to be unsubstantiated at this time.