Complaint Investigation Report

When R1’s door was unlocked by staff, it was 11:00 a.m. and there was a concern that staff had not checked on R1, as R1 was soiled. In addition, the witness could not find a staff person to assist with changing R1. Interviews and observations confirmed that whereas the resident doors locked from the exterior, the lock is disengaged once residents turn the handle from the inside and residents can successfully leave their room. Per records review and interview, although R1 was in their room until 11:00 a.m. on 05/08/2023, it was confirmed that staff continued to conduct status checks on R1. R1 was checked on and assisted with the self-administration of medication at 10:00 a.m. on 05/08/2023.

Interviews and record stated that oftentimes, R1 has trouble sleeping and would often be awake through the night. The LPA reviewed charting notes for 05/08/2023, and it was documented that R1 was awake throughout the night 05/08/2023 until 4:00 a.m. Staff entered the note on 05/08/2023 at 6:16 a.m. and indicated that R1 was asleep ‘at that time’. Notably, staff indicated that is hard to get R1 up in the morning because of R1’s struggles with sleeping, hence R1 will frequently sleep until 11:00 a.m. A review of charting notes and interviews supported claims that due to an infrequent sleeping schedule at night and medication effects, R1 will sleep in their wheelchair mid-morning or will appear drowsy. However, staff and records supported claims that although R1 sleeps late, staff will assist R1 with the self-administration of medication in the morning, and staff will continue to conduct status checks on R1 in the morning to see if R1 wanted to wake up. Staff claimed that in the mornings, R1 will refuse to get up and will ask staff to return at a later time. Staff indicated they will ask R1 if they were ready to get up or to have breakfast, but also recognized they are unable to force R1 to get up because it would have been a violation of their personal rights.

Per the incident on 05/08/2023, a witness claimed that upon seeing R1 at approximately 11:00 a.m., R1 was soiled. At that time, the witness claimed they were unable to locate a staff member to refresh R1 and/or to change R1 into clean clothing prior to providing services to R1. Due to time constraints, the witness provided physical therapy services to R1 without obtaining care assistance from staff. The LPA reviewed the staffing schedule for 05/08/2023 and noted that there were at least four (4) care staff on shift, not including managerial staff. Yet, staff may have been occupied with providing care to other residents. There was no indication that the witness pulled the resident’s pull cord to obtain staff assistance. The witness claimed that they were unable to find a staff person in the immediate vicinity of R1's room.

Based on the information obtained from interviews and record review, there is insufficient evidence to support the claim that staff neglected R1. This allegation is deemed unsubstantiated at this time.