Complaint Investigation Report

Regarding the allegation: Unlicensed staff administered insulin to resident with dementia. It’s being alleged “the former Administrator administered long acting insulin to a resident with dementia.” The investigation revealed the following: 6 out of the 7 staff interviewed, denied, or could not confirm the allegation to be true. S1 states, “I don’t know them to act in that role. S2-4 all state not being aware. S5, while unable to confirm or deny the allegation, states that S7 never came around. S6 states the allegation did happen but does not have any witnesses or evidence that could corroborate the allegation. All residents interviewed (R3-5) were unable to confirm or deny the allegation due to their cognitive abilities. R1 and R2 were unavailable for an interview. W1 states hearing a rumor that coincides with the allegation.

Regarding the allegation: Staff did not assist resident with administration of oxygen. It’s being alleged that a resident did not receive oxygen that was requested on their behalf. The investigation revealed the following: 5 out of the 7 staff interviewed, denied or could not confirm the allegation to be true. S1 states not being sure if R2 was in need of oxygen due to their absence from the facility. S2 states it wasn’t something the facility provided regularly, and it might have been a service provided while on hospice care. S3 states being unaware. S4-5 were both unable to confirm. All residents interviewed (R3-5) were unable to confirm or deny the allegation due to their cognitive abilities. R1 and R2 were unavailable for an interview. W1 was not able to confirm or deny the allegation.

Regarding the allegation: Staffing levels are not adequate to meet the needs of the residents. It’s being alleged that due to low staffing levels residents were unkempt and dirty. The investigation revealed the following: 5 out of the 7 staff interviewed, denied or could not confirm the allegation to be true. S1 states they are unable to speak on the previous time frame but noted that “adequate staff is debatable and is not clearly spelled out in title 22. S2 & S3 states the facility “could always use more help but understands there’s a “shortage everywhere and that they do their best.” S4, did not confirm the allegation but states they didn’t have enough supplies at the time to meet the needs of residents. S5 was unable to give a concise response. S6 states, while there were temp agency staff it wasn’t sufficient, and residents were being left dirty. S7 denies allegation, citing the fact that the facility was working with a “staffing agency” and while they were low on regular staff, they utilized an agency to help them with their staffing crisis. R3 and 4 state their needs are being met. R1 and R2 were unavailable for an interview. W1 states, there weren’t enough qualified staff. “there were temps that did not know the clients. Some really good staff left due to poor management of S7 or were lied on and let go.”