Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff did not provide adequate care and supervision to a resident.

It is alleged that R1 had consumed alcohol and was intoxicated, and staff did nothing to prevent this from happening. LPA reviewed facility House Rules and it is written that residents are allowed to have alcoholic beverages in moderation, within resident rooms, not allowed in common areas. LPA interviewed 4 staff and each denied the above allegation, staff stated that per the house rules residents are allowed to consume alcohol as long as it is in their rooms and in moderation and not taken to the common areas, when residents exhibit chronic issues with alcohol this right may be revoked. LPA interviewed 8 residents and each denied the above allegation and stated they are provided with adequate care and super vision. R1 stated they are able to consume alcohol, drank it in their room and did not take the alcohol out in common areas.

Allegation: Staff denied a resident entry to the facility.

It is alleged that staff refused to answer the phone or door when R1 was ready to return from the hospital. LPA interviewed 4 staff and each denied the above allegation. Interview with S4 revealed that R1 had been admitted to the hospital during the day and later that evening past 10pm resident was brought back via non-emergency transportation, however, the front door is locked (from exterior coming in only) at 9pm for safety of staff and residents and during that time staff were conducting rounds, S2 observed the non-emergency transportation vehicle and instructed other staff to allow entrance. LPA interviewed 8 residents and each denied the above allegation and stated they have never been denied re-entry to facility after being hospitalized. Per interview with R1 resident stated that they were never denied re-entry but did have to wait maybe 5-10 minutes for staff to open the door as it was after hours and the door was locked.

Allegation: Staff did not properly maintain a resident's room.

It is alleged that R1’s room has a foul odor and R1’s clothes, bedding and floor was observed to be covered in throw up, urine and feces for over 6 hours as this was observed upon returning from the hospital. LPA interviewed 4 staff and each denied the allegation and stated that rooms are cleaned regularly with a weekly bedding change and deep cleaning, however, if bedding or floors have urine or feces they tend to it right away. LPA interviewed 8 residents and each denied the allegation and stated that staff clean their rooms and bedding is changed weekly. Interview with R1 revealed that upon returning from the hospital the room was clean and bedding was not soiled.