Complaint Investigation Report

Allegation: Staff mishandled the residents' medications. It is alleged that night shift staff (S1) placed resident (R1's) PRN Lorazepam bubble pack in their backpack. According to information obtained, the Lorazepam's physician order was effective January 2024- June 2024. When R1's family was moving out the resident it was discovered that the PRN bubble pack medication could not be found. House Manager was informed the medication was missing. Manager allegedly had R1's PRN medication on top of their office desk, and stated that the medication had just been received. It is unknown why another bubble pack was ordered if R1 had only been administered 3 PRN pills during January 2024- June 2024. Two (2) out of 8 staff interviewed stated they saw a medication bubble pack that resembled the resident(s) bubble packs in staff (S1's) backpack. Facility Manager was notified of incident. Staff (S1) denied the allegation and stated that when R1 lived at the facility no other residents required night PRN medications. Staff interviewed stated that medications are counted every morning and are to be locked and centrally stored. Out of the six staff that denied the allegation, two staff stated they are not responsible for counting medications and cannot be sure if S1 took R1's medication and placed it inside their backpack. Staff were shown a picture of the alleged backpack that showed a bubble pack sticking out of the bag. Staff stated they do not know which staff the backpack belonged to, but acknowledged that the medication bubble pack should not have been readily accessible to residents in care. Staff were shown the photo depicting an unlocked medication bubble pack. Based on record review and photographic evidence there is sufficient evidence to corroborate the allegation because medications shall be kept kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

Allegation: Staff did not provide adequate care and supervision to a resident. It is alleged that staff showed negligence in caring for resident (R1) because the resident fell twice out of their chair while sitting in the dining room table. Additionally, it was reported that another resident (R4) was hospitalized in May 2024 due to a fall incident. Based on five (5) out of eight (8) staff interviews, the findings indicate that resident (R1) did fall while sitting in the dining room chair, and resident (R4) also sustained 2 falls, one was while sitting on the dining room chair, and the other was in their room where she sustained a large cut on the forearm. According to staff interviews, when resident (R1) fell in the dining area there were staff in the living room area next to the dining area, and R4's fall in their bedroom was not witnessed. Staff protocol is to check on residents every 1-2 hours when they are in their bedrooms and maintain constant supervision when they are in the living and dining room area. Based on record review, the facility did not submit to DSS Community Care Licensing fall incident reports pertaining to R1 & R4's falls. There is sufficient evidence to support the allegation.