Complaint Investigation Report

Regarding allegation: Staff did not check on residents in a timely manner

It is alleged that staff did not ensure resident’s well-being when resident had fallen to the ground. Staff did not respond in a timely manner to aid residents, instead another resident provided assistance to a resident who had fallen. The investigation reveals the following: Residents interviews revealed that four (4) out six (6) stated that they have not experienced any issues with staff responding in a timely manner. The remaining two residents were unable to respond to LPA’s question. R1 stated that R1 has used the bathroom call button and staff has responded to provide assistance. LPA interviewed R1, who stated that there was one instance where R1 had fallen in R1’s bathroom. R1 yelled out for assistance since the call button was out of R1’s reach, however, staff managed to hear R1’s calls for assistance and provided R1 with assistance. Staff interviews revealed that six (6) out of six (6) staff denied not responding to residents’ calls in a timely manner. LPA observed that during facility activities staff were providing assistance to residents in the common area. LPA tested call buttons in two random residents’ rooms, and the response time was less than five (5) minutes. Staff stated that wellness checks are done every two hours, but if residents have special needs, wellness checks are done more frequently. Based upon the investigation, client and staff interviews, and LPA observations, there was insufficient evidence to corroborate the allegation.

Regarding allegation: Staff inappropriately removed the signal systems from residents’ rooms. It is alleged that the signal system pull cords have been removed from residents’ rooms and bathrooms and that residents may not be able to summon staff for assistance when needed. The investigation reveals the following: The signal system was replaced in May/June; however, the new system was operational on the same day that the previous signal system was removed. There was no downtime experienced at the facility during installation and replacement of signal system. Residents’ interviews revealed that three (3) out of six (6) residents stated that they have not needed to use the call button to summon staff for assistance. R1 stated that R1 has used the bathroom call button and staff has responded to provide assistance. R1 stated that there was one instance where R1 had fallen in R1’s bathroom. R1 yelled out for assistance since the call button was out of R1’s reach, however, staff managed to hear R1 calls for assistance and provided R1 with assistance. Two (2) out of six (6) residents were not able to understand questions about the call system. LPA tested the call system on each floor and staff responded in a timely manner, in less than five (5) minutes. Staff interviews revealed that six (6) out of six (6) staff denied not responding to residents’ calls when the signal system button is pressed.