Complaint Investigation Report

Regarding Allegation #1 : Facility did not ensure that resident received prescribed medications.

This complaint alleged that staff did not have prescribed insulin or metformin for C1 use. On 10/12/2023 LPA Calderon obtained and reviewed the physician order (dated 09/23/2023 and 10/04/2023). The order states to take one 500 mg metformin tablet by mouth twice a day with morning and evening meals. MAR for C1 notes that metformin was given to C1 from 10/01/2023 to 10/08/2023. LPA Calderon conducted an interview with A1. A1 states that C1 was a client from 09/28/2023 to 10/08/2023. A1 states that C1 did not arrive at the facility with insulin or metformin. A1 states that staff ordered metformin for C1 on 09/23/2023 and 10/04/2023. LPA Conducted an interview with S1. S1 states that S1 reviewed C1 medical records and metformin was ordered on 09/23/2023 and based on MAR, metformin was given to C1 from 10/01/2023 to 10/08/2023. LPA Calderon could not interview C1 as C1 moved out of the facility on 10/08/2023 and C2 is non-verbal. LPA Calderon conducted an interview with C3. C3 states that staff has never run out of C3 medications and has never missed giving C1 medications on time.

Regarding Allegation #2 : Facility is not following resident’s dietary plan.

This complaint alleged that staff did not follow R1 diabetic meal plan by serving R1 cereal. On 10/12/2023 LPA Calderon obtained and reviewed the physician report (dated 09/21/2023) The physician report states C1 has type 2 diabetes and a diabetic diet is suggested. LPA Calderon conducted an interview with A1. A1 states that C1 is conserved and that C1 mother advised staff that C1 only likes cereal in the morning and at night and to serve a meal for lunch. A1 states that there was no diabetic meal plan for C1. LPA Calderon conducted an interview with S1. S1 states that S1 reviewed medical records for C1 and noted C1 was diabetic. S1 spoke to C1 conservator who advised S1 that C1 only would eat cereal in the morning and at night. S1 states that staff called C1 doctor office on 09/26/23 and 09/27/23 to have the physician order a dietetic meal plan for C1 but there was not enough time and C1 moved out on 10/08/2023. LPA Calderon could not interview C1 as C1 moved out of the facility on 10/08/2023 and C2 is non-verbal. LPA Calderon conducted an interview with C1. C1 states that C1 is not diabetic, and that staff serves 3 meals per day.