Complaint Investigation Report

Regarding the allegation: Facility has insufficient staff for the residents while in care

It was alleged that the facility was severely understaffed. Interviews and records indicated that fully staffed meant there were at least two medication technicians and three to four caregivers for the AM shift (6 a.m. – 2 p.m.) and PM shift (2 p.m. – 10 p.m.). At times, there is only one (1) medication technician in the PM shift. Staffing is also based on the needs of the current residents within the facility. Staff admitted that at times, if someone calls off, staff will need to supplement with agency staff, assign a medication technician to also conduct caregiving duties, or management staff will step in. Staff interviews confirmed that in January 2023, management staff had to step in and conduct caregiving duties for certain shifts due to staff calling off work. Although some staff indicated that additional staff members were needed, the majority of staff felt that there was sufficient coverage to manage resident care needs. Similarly, most residents interviewed indicated that care needs have not suffered or gone unmet due to staffing concerns. The LPA reviewed pendant logs from 06/15/2023 – 07/10/2023 and uncovered that generally, staff respond to resident pendant calls within 4-8 minutes. Whereas there were some response times that went between 10-15 minutes, it was not most of the pendant calls and represented sporadic occurrences. Based on the information obtained in interviews and record review, there is insufficient evidence to support the claim that facility has insufficient staff for residents while in care. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident sustained injuries from a fall while in care

It was alleged that due to neglect, Resident #1 (R1) sustained injuries from a fall. Records indicated that on 01/26/2023, R1 suffered an unwitnessed fall in their room. Due to the fall, R1 had a large skin tear on their left hand. When 9-1-1 arrived and R1 was being assisted onto the gurney, records indicated R1 collapsed on the floor and suffered an additional skin tear on the right leg. R1’s needs and services plan indicated R1 was a fall risk, required escorting to meals and activities, needed reminders to use their cane and walker if observed ambulating without the device, and R1 required reminders to ask for assistance when ambulating. Regarding toileting, R1’s plan documented that staff had to assist R1 with changing their briefs when necessary. A review of charting notes for R1 documented that on 01/07/2023, R1 complained of pain and stated that they tried to go to the bathroom and had almost fallen. Due to weakness, R1 was sent to the hospital. R1 was discharged back to the facility on 01/11/2023, and it was documented that R1 reported that they would ‘press [the] pendant if [they] were not feeling well and when [R1] needed to use the restroom’.