Complaint Investigation Report

To investigate this allegation on 01/27/2023 LPA conducted interviews with the administrator, staff, and residents. LPA also obtained records specific to the allegation. Administrator and SIR confirmed on the way back from an outing staff gave R1 medication meant for resident #2 (R2) while in a moving vehicle. According to the Administrator R1 required medical attention and was not themselves immediately after the medication error. In an interview conducted 03/01/2023, Administrator stated corrective action was being processed by human resources. All staff involved, staff #2 (S2), staff #3 (S3), and staff #4 (S4) was assigned mandatory training on medication through the facilities training portal. This is an immediate health and safety risk to clients in care. Based on the information revealed during interviews and record review, the allegation is SUBSTANTIATED at this time.

Allegation #2: Staff is sleeping during shift hours

It is alleged S2 falls asleep on shift. To investigate this allegation on 01/27/2023 LPA conducted interviews with the administrator, staff, and residents. Administrator, staff, and residents revealed S2 falls asleep while on shift. Administrator states it was brought to their attention by other staff and they have had conversations with S2 about falling sleep while on shift. According to the Administrator, they have moved S2 from the evening shift to day shift to help remedy the issue. S2 agreed to move to morning shift. Based on the information revealed during interviews, the allegation is SUBSTANTIATED at this time

Deficiencies cited on LIC 9099 D. Immediate Civil Penalty assessed. Immediate Civil Penalty issued (refer to LIC421IM). Appeal Rights explained. Exit Interview conducted.