Complaint Investigation Report

Regarding the allegation "Resident sustained unexplained injuries while in care,” it is being alleged that Resident #1 (R1) sustained a black eye in January 2025 and a scrape/cut on knee in March 2025.

Record review of R1’s Mobile Physicians Report (01/23/25) revealed that R1 did not have swelling or tenderness of the face over the periorbital area of the right eye during the standard exam. The report also described problem #2 as a contusion of the periorbital area on the right. Four out of four Staff (#1 – 4) interviews indicated R1 did not have a black eye. Interview with Staff #1 (S1) and Staff #3 indicated that it is possible that R1’s face hit the table while R1 was asleep in R1’s chair while wearing glasses. S1 indicated that staff tries to encourage R1 to sleep in the bed but R1 would eventually go back to the chair. Interview with S1 and Staff #2 (S2) indicated that R1 had a little bump on R1’s knee and R1 scratched it. They added a bandage but R1 removed it. Interview with Resident #2 (R2) indicated R2 has not sustained any unknown injuries while in care and is unaware if other residents had sustained unknown injuries. Interview with Witness #2 indicated Resident #3 has not sustained any unknown injuries while in care and is unaware if other residents had sustained unknown injuries.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff mismanaged resident's medications

Regarding the allegation "Staff mismanaged resident's medications,” it is being alleged that Resident #1 (R1) was given the wrong medication and was unrecognizable the last week of February and the beginning of March 2025.

Medication Administration Record (MAR) revealed that R1 took Quetiapine 100mg and Divalproex 250mg twice per day in February 2025. In addition, on 02/06/25, R1 started taking Sertraline HCL (Zoloft) 50mg. On 02/17/25, R1 started taking Sertraline HCL (Zoloft) 100mg daily. Plus, on 02/25/25, R1 started taking Trazodone 50mg twice per day from 02/25/25 – 02/28/25. Record review of Mobile Physician report (03/06/25) revealed Quetiapine 100mg was prescribed twice per day as of 01/16/25. Divalproex 250mg was prescribed twice per day as of 04/25/24. Record review of Mobile Physician report (faxed 02/04/25) revealed Zoloft 50mg was prescribed once per day.