Complaint Investigation Report

Allegation: Facility staff are not providing resident with appropriate supervision, resulting in falls.

It was reported that resident fell several times due to staff not coming to assist them upon request. LPA reviewed schedule for October 2024. From 10/1/24 thru 10/22/24 the schedule list time of supervision and whom the resident is being supervised by. LPA also request copies of all fall Special Incident Reports(SIR) and LPA did not receive not one report for R-1 nor did LPA find any copies of SIRS received for R-1 in Community Care Licensing Division (CCLD) faxes received.

LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, is staff providing appropriate supervision to avoid resident falls? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, are staff providing sufficient supervision?” Of those interviewed, 6 out of 8 answered yes, 2 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Facility staff are not providing resident with appropriate supervision, resulting in falls,” therefore the allegation is unsubstantiated.

Allegation: Staff are mismanaging resident's medication

It was reported that R-9 did not receive medications on 9/24/24 and 9/25/24. On 10/22/24, LPA requested, received and reviewed copies of R-9’s electronic Medication Administration Record and upon review, LPA observed that all medications were administered per doctor’s instructions. The electronic MAR also has the initials of the tech and the times that the medications were administered.

LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, if staff were mismanaging the resident’s medications? Of those interviewed, 8 out of 9 answered no, and 1 said they didn’t know. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, does staff mismanaging your medications?” Of those interviewed, 6 out of 8 answered no, 1 answered yes and 1 does not receive medication at this time. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are mismanaging resident’s medication,” therefore the allegation is unsubstantiated.