Complaint Investigation Report

Interview with Administrator and responsible parties with knowledge of the situation revealed that R1 later informed staff that R1 fell because they suddenly felt weak attempting to get out of bed. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that resident sustained unexplained injuries. Therefore the above allegation is UNSUBSTANTIATED at this time.

It was alleged that lack of supervision resulting in resident leaving the facility. LPA records review of R1's physician's report revealed, that R1 was able to leave facility unassisted and did not require 1:1 care supervision. LPA interview with staff and other responsible parties revealed that R1 may have been in the smoking area near the parking lot of the facility and then exited the premises through the gate. Interviews further revealed that R1 would leave facility on occasion, to go to the store, but R1 would always return. LPA schedule review revealed there to be sufficient amount of staffing at the time R1 eloped from the facility. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that there was lack of supervision resulting in resident leaving the facility. Therefore the above allegation is UNSUBSTANTIATED at this time.

It was alleged that Resident #1 (R1) was illegally evicted. It was reported that R1 was being evicted from the facility. Interviews conducted revealed that R1’s responsible parties visited R1 in the hospital on 11/9 following the incident. Interviews with the responsible parties and hospital staff revealed that R1 required a higher level of care and supervision than what the facility could offer. On 11/16 R1 was discharged to a local Skilled Nursing Facility. It was further revealed that the Administrator kept all of R1s personal belongings in R1s room throughout R1s hospital stay until discharge to Skilled Nursing Facility. Additionally, record review revealed there was no eviction notice in file and no eviction notices was submitted to Community Care Licensing (CCL) for R1. Based on interviews and information gathered and reviewed, the Department does not have sufficient evidence to support the allegation of “illegal eviction”. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report issued and sent via email.