Complaint Investigation Report

Allegation: “Staff did not address a resident's change in medical condition.” It is alleged that facility staff did not report R1’s change in condition. Interviews conducted by Investigator Hector revealed that R1's cognitive and behavioral responses, which would become more intense at night, had gotten worse. Additionally, R1 had (6) unwitnessed falls, (4) of which resulted in hospitalizations. However, the only change the facility staff made to R1's supervision was to increase their monitoring of R1. (1) of the staff interviewed confirmed that R1 needed a higher level of care. The current facility administrator was unable to provide any documentation from the previous administration's reappraisal of R1, except for a documented statement that R1’s “Assessment will be updated.” The failure of the staff to address and document R1’s change in medical condition corroborates this allegation.

Based on statements and interviews conducted, as well as reviewed files and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED .

Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to Subashsani Kumar, Executive Director along with the Appeals Rights.