Complaint Investigation Report

The allegation of “Staff did not meet resident's medical needs.” alleges that the facility did not assist resident #1 (R1) in conducting a medical appointment with their physician. LPA interviewed R1 who revealed that recently they were supposed to have an in-person medical appointment with their physician earlier in the month. R1 revealed that they were unable to attend the appointment in-person due to issues in arranging the transportation. R1 stated that the visit was conducted via telephone call instead. LPA interviewed the Administrator who stated that R1’s doctor is in another city and family of R1 had not arranged transport to the medical appointment. Additionally, the Administrator revealed that during R1’s stay at the facility R1 has missed a total of two (2) appointments due to issues with arranging transportation. LPA reviewed R1’s admission agreement to the facility. LPA observed the following entry in the admission agreement, “Transportation-Responsible persons may and are encouraged to provide basic transportation. Facility may provide resident with transportation when responsible person or an alternative arrangement is unavailable, to be billed at a minimum of $30.00 per hour or any portion of an hour to cover driver and/or caregiver escort.” LPA informed that Administrator that per the signed admission agreement the facility agreed to provide transportation to medical appointments for R1. The Administrator expressed understanding and confirmed that they would assist residents in arranging transportation to future medical appointments. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Staff did not meet resident's medical needs.” Therefore, the allegation is deemed Substantiated at this time.

The allegation of “Staff did not administer resident's medications as prescribed.” alleges that the facility did not administer R1’s medications as prescribed. LPA interviewed R1 who stated that they believe the facility is not administering all of their required medications. LPA reviewed R1’s hospital paperwork dated 04/07/2025. LPA observed R1’s hospital paperwork to contain prescriptions for seventeen (17) medications and one (1) medical device. LPA conducted a medication review for R1. R1’s centrally stored medication and destruction record sheet was observed to contain six (6) medications. LPA asked the Administrator where the rest of R1’s medications were. The Administrator stated that the family of R1 has not dropped off the remaining medications. The Administrator stated that the facility has been waiting for the family to obtain the medications and has not made an effort to get R1’s prescribed medications yet. The interview with the facility’s other resident did not reveal concerns with their medication administration. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Staff did not administer resident's medications as prescribed.” Therefore, the allegation is deemed Substantiated at this time. Continued on LIC 9099C.