Complaint Investigation Report

On 09/09/2021 the administrator stated “C1 was in line to get breakfast when someone in front dropped their oatmeal on the floor, C1 tripped but staff was able to assist C1 right away. I did not write an incident report because C1 was not injured. I had C1 taken to get x-rayed. Record reviews indicate that C1 was seen by their Primary care Physician on 06/03/2021 and 06/14/2021 about left knee from slipping on oatmeal around 06/02/2021. On 06/16/2021 X-rays were interpreted from C1 no fractures were observed. On 10/14/2021 8 out of 10 clients interviewed denied sustaining falls while at the facility C2 stated “No. But if I ever do, I would tell staff about it.” 2 out of 10 stated they did sustain falls. Client C3 stated “I fell outside in the parking lot.” C4 stated “Yes, sometimes my blood pressure goes up and down.” Regarding the allegation; Resident sustained fall while in care. Although the allegation may have happe ned or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation; Staff are not administering medications as prescribed. On 09/09/2021 client C1 stated: "The nurse aid discontinued the medication; I would like to know why. They did not show me the discontinue order. This happened about 3 weeks ago in the evening." Staff S1 stated: “One night after the doctor made the order to discontinue the sliding scale administration of C1’s medication, C1 demanded for the caregivers to give them the medication. I told C1 over the phone that the doctor has issued a new order and discontinued it. But C1 was still upset.” On 09/09/2021 record reviews indicate that C1’s medication was discontinued as a sliding scale administration (PRN) and has given a new order to be administered twice a day before breakfast and dinner. On 10/14/2021 10 out of 10 clients interviewed confirmed that staff provided them medications as prescribed. Regarding the allegation; Staff are not administering medications as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation; Staff are not assisting the client with self-administration of their PRN medication. On 09/09/2021 C1 stated “Staff refused to give me Tylenol and Benadryl and I would have to buy.” S1 stated “C1 never asked me for Tylenol or Benadryl. S2 stated “I usually give it to them when they ask.” On 10/14/2021 9 out of 10 clients interviewed stated that they get helped whenever they needed nonprescription pain or cold medications. 1 out of 10 clients disagreed, C5 stated “Sometimes there are no medications when I ask.” Staff S3 stated, “Sometimes, when we run out. We'll tell administrator, then we re-stock.” Regarding the allegation; Staff are not assisting the client with self-administration of their PRN medication. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.