Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff do not distribute resident's medication as prescribed.

It is alleged that on 3/16/2025 and 3/17/2025, staff did not distribute C1 their medication or vitamins and when asked for them staff stated that they were withholding because of C1s mood. LPA reviewed 3 clients medications (including C1’s) and MAR’s all medication to be given as prescribed and signed by staff, there were no notes or observations made of medication errors, all medication refusals were properly documented and accounted for in their proper package . LPA reviewed C1’s IPP and ABC’s in which it is documented that C1 has ongoing history of medication refusal and making false allegations. LPA interviewed 4 clients and 3 out of 4 clients denied the above allegation and stated that staff have given them their medication daily and as prescribed. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation stating all medications are given as prescribed to clients, although at times clients may refuse medication, multiple attempts will be made and if they still refuse staff document information and generate an incident report.

Allegation: Staff do not assist resident with obtaining medical care.

It is alleged that on 3/16/25 C1 was not feeling well and asked staff to call emergency/911 and staff refused to call or give C1 medical attention. LPA interviewed 3 clients and 2 out of 3 clients denied the above allegation (the 4 th client terminated interview after answering questions pertaining to the first allegation), clients stated that they are able to call for emergency services on their own either using their personal phone or facility landline, 3 clients confirmed they have called emergency services in the past, and 2 clients denied that staff refuse to assist with their medical care. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation stating that when emergency services are needed 911 is called. Interview with S2 revealed that in the case of emergency 911 is called however, if they are suffering a mental crisis staff try to de-escalate situation and use their resources (therapist/crisis prevention team) to assist prior to calling 911, but if needed and unable to de-escalate 911 will be called. During file review LPA observed an emergency visit for C1 dated 3/17/25, where C1 was sent to hospital for medical care.