Complaint Investigation Report

Regarding Allegation #1 : Staff did not provide adequate supervision resulting in residents wandering away from facility.

This complaint alleged that R1 wandered away from the facility. LPA Calderon interviewed with A1. A1 stated that on 07/26/2022 R1 followed a guest out the front door of the facility at 1 pm. Staff searched for R1 when unable to locate inside the facility and then called 911. According to the police report #22-76564, R1 was found blocks away from the facility and was unharmed. LPA Calderon interviewed with S1-S3. 3 out of 3 staff admitted that R1 did wander away from the facility on 07/26/2022 and was recovered with no injuries in tack. facility. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2-R3 acknowledged that R1 did wander away from the facility due to the failure of staff supervision. On 11/02/2023 LPA Calderon reviewed the physician’s report (dated 03/07/2022) for R1. The report indicated R1 has a wandering behavior and requires observation and supervision.

Regarding Allegation #2 : Resident has lost significant amount of weight while in care.

This complaint alleged R1 lost a significant amount of weight while in care. LPA Calderon interviewed with A1. A1 stated that R1’s weight on 03/07/2022 was 136 lbs. and that R1 lost 15 lbs. A1 stated that staff did not keep track of R1’s weight, but that A1 had called R1 sister to advise that the facility would need a new doctor’s order regarding R1 weight. A1 stated there were no responses from the R1 family for the new doctor’s order. A1 claimed that the weight loss was not due to overmedication of quetiapine. LPA Calderon interviewed with S1-S3. 3 out of 3 staff stated that most residents lose some weight until they get familiar with the facility and food and then usually gain weight. 3 out of 3 staff stated that R1 did lose some weight which is normal for a new resident. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2-R3 stated that new residents usually must get used to the food and lose some weight. R2-R3 reported that they also lost some weight at first but gained weight after getting used to the food being served. On 11/03/2022 reviewed food log notes (dated September 2022) for R1. The percentage of food consumed by R1 is logged in the log. It appears R1 ate 90% of his breakfast, 50% of his lunch, and 10% of his dinner. There were no logs of any changes to R1 weight.