Complaint Investigation Report

(PAGE 2) Report Continued from LIC9099....

On todays visit LPA Mosley conducted a physical plant tour at 9:45 a.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. At 10:04 a.m. LPA and Administrator Designee inspected food items in the two (2) refrigerators and two (2) freezers in the kitchen area to check for proper labels and expiration dates, at 10:44 a.m. conducted a medication audit on all six (6) residents, At 11:30 a.m. conducted an audit on facilities P&I records of the four (4) residents receiving P&I funds, from 11:49 a.m. – 1:15 p.m. Interviewed five (5) out of six (6) residents, from 1:20 p.m. – 2:00 p.m. interviewed two (2) staff including the Administrator Designee and reviewed relevant documents pertaining to the investigation.

On the allegation Staff is mismanaging resident's medications it is the concern of the Reporting Party (RP) that the facility staff are mismanaging residents’ medication including Resident #1 and Resident #6. To investigate this complaint, LPA conducted a medication audit on all six (6) residents. Medication audit revealed that medications are centrally stored and locked inaccessible to residents in care in a kitchen cabinet. The audit revealed that the facility was not accurately documenting the medication start dates on the Centrally Stored and Medication Record for six (6) out of six (6) residents which poses a potential health and safety risk to residents in care. LPA and Designee discussed the importance of record keeping and the potential health and safety risk in not adding accurate start dates. Based on information obtained, and medication audit there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff is mismanaging resident's medications is deemed substantiated at this time.

On the allegation Staff do not properly store and dispose facility food it is the concern of the Reporting Party (RP) that the facility staff are not properly storing and disposing facility food including not labeling food properly. To investigate this complaint, LPA inspected food items in the two (2) refrigerators and two (2) freezers in the kitchen area to check for proper labels and expiration dates. Inspection revealed that the facility had multiple items that were not properly dated including two (2) containers of left over food, two (2) containers of cooked bacon, along with cheese wrapped up in foil paper and various frozen vegetables in bags which poses a potential health and safety risk to residents in care. LPA and Administrator Designee spoke about the importance of proper documentation when putting items in the refrigerator and freezer. Based on information obtained, and food inspection there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not properly store and dispose facility food is deemed substantiated at this time.