Complaint Investigation Report

On 04/20/2022, LPA Walker conducted a subsequent complaint inspection for the above allegations. During the visit, the LPA conducted a physical plant tour with Business Office Manager, Katia Arriaga, at 9:31 a.m. From 9:55 a.m. until 10:45 a.m., the LPA reviewed and obtained copies of documents pertinent to the investigation. From 11:10 a.m. until 12:30 p.m.; and, between 3:10 p.m. until 3:45 p.m., the LPA conducted interviews with facility staff. From 1:52 p.m. until 3:10 p.m., the LPA conducted interviews with facility residents. The LPA determined further investigation was required at that time.

Regarding the allegation, ‘Staff did not respond to residents call button ,’ the complainant’s concern is that Resident #1 (R1) had a device that is supposed to alert staff when R1 falls; however, the complainant alleged that they were informed that staff never came after the falls. The complainant is also concerned that when staff did not respond to the call button, R1 then had to yell for staff to assist R1.

LPA Walker attempted to contact the complainant and R1’s family member, as R1 passed away, but did not receive a response.

LPA Walker also conducted interviews with the administrator and facility staff; as well as a record review. The administrator revealed that R1 had a pendant provided by the facility that detects falls; so, it would have detected if R1 fell. The administrator also revealed that R1 would not wear the pendant. The administrator recalled an incident where R1 was found by the facility Medication Technician (Med Tech) on the floor; however, R1 was not wearing their pendant. According to the Administrator, staff response time to pendant calls is between 1 to 5 minutes; and, the highest wait time would be around 11 minutes.

Interviews with staff revealed that facility staff are provided a “pager” that notifies all staff when residents press on their call button or a fall is detected. Staff also confirmed that R1 would take off the pendant and the Med Tech would ask R1 why they kept taking it off. R1 would state that they forgot. There were also times that R1 would take off their pendant and staff had to look everywhere to try and locate it. Interviews with staff also revealed that due to R1’s decline in health condition, the facility had to conduct more routine checks to monitor R1.