Complaint Investigation Report

Regarding: Staff does not ensure resident’s special dietary plan is followed.

It is alleged that staff does not accommodate resident’s special dietary needs even though the information is noted in their file due to their health condition. It is also alleged that staff will not allow resident to have hot, vegan-based meals even though they cannot eat meals from the regular menu.

Interviews with (9) out of (9) staff indicated that the facility ensures that residents’ dietary plans are followed. Seven (7) out of (9) staff indicated that they follow meal service guidelines to meet the dietary needs of residents, including those who have special dietary needs. Staff stated that R1’s dietary plan consists of having plan-based items which the kitchen has available. Staff indicated that the facility has an alternative menu which provides hot and cold vegetarian and vegan and plant-based options; however, R1 has not placed orders for those items, yet. Staff stated that R1 has been informed regarding the plan-based options. Staff also indicated that the kitchen makes meal accommodations for residents, including R1 according to their meal preferences if they provide reasonable advance notice to kitchen staff to ensure timely preparation. Furthermore, (3) staff have stated that R1’s Physician Report information regarding R1’s meal modifications have been discussed during in-service training with staff. Interviews with (12) out of (13) residents indicated that the facility provides meals which meet their dietary needs and have no concerns. LPA reviewed the kitchen’s Special Dietary Needs binder and observed that R1’s Physician Report and meal plan is in place. LPA observed the kitchen’s pantry and refrigerators and observed plant-based items readily available. Interviews, observation and record review cound not corroborate the allegation that the facility is not ensuring that resident’s dietary plan is followed.

Regarding: Staff does not ensure resident’s care plan is being followed.

It is alleged that day staff are supposed to check on resident every 2 hours, but instead neglect their care and don't follow their care plan.

Staff deny the allegation. Interviews with (6) out of (6) staff indicated that staff are conducting wellness checks on residents according to their Care Plan. Staff indicated that R1 is checked (4) times per shift by caregivers and staff from other departments as indicated in R1’s Care Plan. Staff indicated that not only are wellness checks conducted in resident rooms, but also in the common areas and any place residents spend time in within the facility. Staff indicated that R1 steps out of their room during meals and other activities and therefore, staff check on R1’s well-being wherever R1 is at the facility, not just in their room. Staff indicated that R1 is sometimes sleeping and is not disturbed by staff during wellness checks and R1 may not notice staff checking in on them. Staff further indicated that they educate R1 on calling on staff in between checks if needed; however, R1 seldom makes calls to staff requesting a visit in between wellness checks***Continues on LIC 9099-C page 2***