Complaint Investigation Report

The documentation further showed that staff provided meals to R1 during the quarantine period; however, R1 at times refused food and became verbally aggressive despite repeated staff efforts to provide assistance. In addition, LPA conducted five staff interviews and five resident interviews, and all individuals interviewed denied the allegation. LPA also confirmed through staff interviews and LPA observations that the facility maintains a supply of personal protective equipment (PPE) for use as needed. During record review, LPA verified that staff had received training on infection control procedures and protocols to follow in the event of an outbreak.

Regarding the allegation that the resident experienced several falls due to neglect, facility records reflected that on August 10, 2021, R1 was found by staff lying on their back in the hallway and complaining of back pain. The fall was unwitnessed. Out of precaution, the facility arranged for R1 to be transported to a local hospital for evaluation. According to the facility’s documentation, R1 did not sustain any fractures and was later discharged from the hospital. Per records reviewed there were no other falls documented for R1. LPA was unable to interview R1 due to R1 moving out of the facility.

Regarding the allegations that the resident had scabies and ringworm, LPA reviewed R1’s records and found no documentation confirming either diagnosis. Progress notes dated July 2, 2021, indicated that R1 developed a rash on the left ankle, which was treated as directed by the resident’s physician. All treatments were recorded by the facility’s Medication Technician. Five staff were interviewed and reported direct knowledge of R1 and reported R1 did not have any diagnosis of scabies or ringworm. Five residents were interviewed who reported they had no knowledge of residents in care having scabies or ringwork.

Regarding the allegation that staff mismanaged residents’ medications, LPA interviewed five staff members who handle resident medications who reported having no knowledge of R1’s medications being mismanaged. LPA interviewed five residents who denied having issues with medications not being received timely and/or receiving incorrect medications. LPA observed facility medication administration process during visits. incorrect medications. LPA observed facility medication administration process during visits.