Complaint Investigation Report

LPA obtained copies of the staff/ resident rosters; and resident files for Resident #1 (R1) with relevant information.

The investigation revealed the following:

In regard to: facility did not accept resident's prescribed medication, it was alleged that staff did not take a glucose meter from resident's responsible party. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. Resident interviews revealed that staff administer residents’ medication as prescribed including their diabetic care needs. All staff interviewed denied the allegation. Staff interviews revealed only LVNs or medical professionals were allowed to administer glucose check using glucose meter if it was prescribed by physician orders. Per record reviews, the resident was on hospice care. There was no prescription or doctor's order to instruct the facility to conduct glucose test or use glucose meter on the resident. As a result, facility did not have physician order on administering glucose test or accepting glucose meter.

In regard to: staff locked resident's wheelchair, it was alleged that the wheels on the resident’s wheelchair were locked while resident was in resident's room. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. Resident interviews revealed that their wheelchairs were locked for safety purposes, such as dining in dining room. Staff would unlock residents' wheelchairs after meals. All staff interviewed denied the allegation. Per staff interviews, it stated staff were not allowed to lock the wheels of residents' wheelchairs, unless for safety reasons. Per record reviews, it indicated that resident was able to unlock the wheels. Per LPA's observation, the residents in wheelchairs were able to move around and staff would assist residents if their wheelchairs got stuck. Thus, there was not preponderance of evidence to show staff locked resident's wheelchair.

In regard to: facility did not ensure that resident was properly dressed, it was alleged that staff did not check on resident#1 (R1) to ensure resident was clothed appropriately. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. Resident interviews revealed that staff dressed residents every morning and clothed them properly. All staff interviewed denied the allegation. Staff was instructed to check and change R1’s diaper every two (2) hours which staff would clean and dress R1 every two (2) hours. Per LPA’s observation, residents were dressed properly. Therefore, staff dressed residents decently. (-continued in LIC 9099 C-)