Complaint Investigation Report

Allegation: Staff did not provide resident with special diet according to resident’s health care needs.

The allegation alleges that some residents have a special diet and the meals served are high in fat, sodium, and carbohydrates.

During interviews with staff (S1-S3), were asked if residents special diet orders are followed, three (3) out of three (3) stated they follow resident’s special diets from their physicians. Interviews with Residents (R1-R5) three (3) out of five (5) stated they do not have any dietary restrictions. Residents R2 and R5 stated they have dietary restrictions and that they are served things they should not be eating due to their health conditions. R5 stated they are served sandwiches on white bread with high sodium meats. R1 stated they are given carbohydrates LPA reviewed physician’s orders for R1, R2, and R5, and found they required a special diet of low sodium, low carbohydrates, and low sugar. LPA reviewed the sample menu and observed many of the item are high in carbohydrates.

Allegation: Staff did not dispense medications as prescribed

The allegation alleges that medications are not properly dispensed even after doctors and nurses have conferenced with onsite caregiver.

During record review of the Resident’s medication administration record (MAR), LPA observed the MAR did not have accurate documentation of medications administered to residents. Additionally, LPA observed R1 has two (2) PRN