Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff are not providing adequate supervision to residents in care . It is alleged that all night shift staff fall asleep. Some staff interviewed stated they had not worked the night shift and denied seeing any staff member asleep. Staff stated they received training in supervision and safety procedures, as well as clients’ rights. Interview with S1 revealed that S5 was written up for sleeping during shift. Additionally, S1 stated that a written disciplinary action had been taken against S4–S5 and they had received a warning for unsatisfactory performance. S1 also confirmed the night shift staff in the photos sleeping and stated a zero tolerance policy about being neglectful of the clients. C1-C2 corroborated the allegation, stating they witnessed S4-S5 asleep and snoring on the sofa frequently while on night duty. The Regional center confirmed that there is no on-going investigation and did not receive a similar complaint. Documents review indicated S4-S5 did not adhere to the client’s supervision needs or care plans. Therefore, there is sufficient evidence to corroborate the allegation.

Allegation: Staff do not administer resident's medication in a timely manner. I t is alleged that night shift staff give clients’ medicine late. Some staff interviewed stated they had not seen the night shift staff administer medication late because it was after their shift. S1 confirmed that due to different reasons, some staff members administered medications late or committed medication error. S1 indicated that staff members document daily notes and the MAR in addition to reporting medication mistakes to them. All staff interviewed confirmed that they completed medication training and agreed that a medication is considered late if it is administered more than one hour before or after the scheduled time. C1-C2 corroborated the allegation, stating they are often given their medication late, especially during the evening and bedtime medication passing. The Regional center confirmed that there is no on-going investigation and did not receive a similar complaint. Documents reviewed showed that CCLD received incident reports of medication errors. Therefore, there is sufficient evidence to corroborate the allegation.

Based on statements and interviews conducted with clients and staff as well as reviewed files and documentation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to LaTonya King, Administrator along with the Appeal Rights.