Complaint Investigation Report

LPA attempted to identify the residents referenced in the complaint using room numbers, physical descriptions, and available facility records. Facility admission records showed that R1 was admitted to the facility on April 1, 2024, and R2 was admitted to the facility on February 23, 2024. At the time of the investigation, R1 and R2, who were identified as the alleged victim residents, no longer resided at the facility and had moved out.

Regarding the allegation that “Staff do not assist residents self-administer their medication,” the complaint alleged that two residents had mixed up paper cups containing medication and were unsure which medication to take. During the investigation, LPA reviewed the LIC 602 Physician’s Reports, facility progress notes, admission records, and medication records for Resident 1 (R1) and Resident 2 (R2) from February 2024 through August 2024. The records reviewed did not show documented medication errors, missed medication doses, or concerns related to medication assistance. The records reflected that medications were documented as provided by MedTech staff. LPA also interviewed six residents and six staff members regarding medication assistance and facility medication procedures. Staff interviewed denied leaving medication unattended with residents and denied knowledge of the alleged incident. Six out of six staff members interviewed did not provide statements corroborating that residents were left with medication cups, that medications were mixed up, or that residents did not receive medication assistance as required. Six out of six residents interviewed did not report concerns regarding medication assistance or staff failing to assist residents with self-administered medications. During the walkthrough, LPA observed medication being dispensed by a MedTech. LPA observed the MedTech verify the resident’s name against the name on the medication, confirm the resident’s room number, and compare the resident’s photograph with the resident being assisted. LPA further observed the MedTech provide the medication to the resident and remain with the resident until the medication was safely taken before proceeding to the next resident.

Regarding the allegation that “Staff do not ensure residents were adequately hydrated,” the complaint alleged that a resident was hospitalized and was reportedly informed by hospital personnel that the resident was severely dehydrated.