Complaint Investigation Report

The investigation revealed the following: Allegation #1 Staff did not seek timely medical attention for a resident.

The details of the complaint alleged that the facility did not seek timely medical attention for the resident and that the resident was in severe pain. It was reported that the staff stated the resident was transitioning and only contacted hospice. On 04/04/24, from 10:30am-2:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. R1 could not be interviewed because R1 has moved to another facility and was not cognitively coherent to answer pertinent questions. 3 of 3 staff denied the allegation Staff did not seek timely medical attention for a resident. S1-S3 stated that all residents receive timely medical attention and that every measure is taken to ensure that medical needs are met according to their care plan. Staff further state that when residents are on hospice, they can only call the hospice agency and are only given comfort measures. Staff stated that on 01/03/2023 the hospice agency was notified, and the family was too because R1 was in severe pain. LPA reviewed the SIR (Dated 01/04/2023) submitted by the facility and did not find any discrepancies in the time it took to notify the proper authorities of the residents’ medical issues in a timely manner. LPA further reviewed the hospice plan of care (Dated 12/02/2022) that allowed for a comfort kit (morphine sulfate 20mg/0.25ml) if the resident was in pain. LPA interviewed R1-R4 about the allegation that the Staff did not seek timely medical attention for a resident. 3 of 4 residents that were interviewed stated that when medical attention is needed the facility gives them timely medical attention and that they are satisfied with the care and supervision given by the staff.

Based on interviews and records reviewed there is insufficient evidence to support the allegation that Staff did not seek timely medical attention for a resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated .

Allegation # 2- Staff did not have accurate records for a resident.

The details of the complaint alleged that the facility did not have accurate medication records for the resident in care. On 04/04/24, from 10:30am-2:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. R1 could not be interviewed because R1 has moved to another facility and was not cognitively coherent to answer pertinent questions. 3 of 3 staff denied the allegation that Staff did not have accurate records for a resident. S1-S3 stated that R1s records were up to date. LPA reviewed R1’s Medication Administration Record (Dated October -January 2023), Physicians Report LIC602 (Dated 07/04/2022), Daily Monitoring Record (Dated October 2022 -January 2023), and Hospice Plan of Care (Dated 12/02/2022) and did not find any discrepancies in R1’s record. LPA interviewed R1-R4 about the allegation and 3 of 4 residents that were interviewed denied the allegation that Staff did not have accurate records for a resident. Residents stated that they believe that all records were accurate and that they believed that the facility had up to date records of their medical issues.