Complaint Investigation Report

Regarding the allegation that the facility allows resident's medication supply to run out: Per staff statements, facility medication technicians and nurses are trained to reorder once-a-day medications 7 days in advance and twice-a-day medications 14 days in advance to ensure medications do not run out. Medication audits are also regularly conducted. LPA interviewed AD and the Wellness Director who denied the allegation and stated there are no issues with medications at the facility. LPA interviewed 10 residents and 3 residents stated they received assistance with medications. LPA reviewed MARs for these 3 residents for the past 3 months and observed that 2 of these residents, Resident #1 (R1) and Resident #2 (R2), had missed doses of medications due to the facility running out of supply, including 6 missed doses of Sertraline HCl Tablet 100 MG, 2 missed doses of Klor-Con 10 Oral Tablet Extended Release 10 MEQ (Potassium Chloride), and 1 missed dose of Furosemide Oral Tablet 20 MG (Furosemide). Per the Mayo Clinic, Sertraline is used to treat depression and other psychiatric disorders and missing several doses of an antidepressant may cause discontinuation syndrome the symptoms of which include agitation, sleep disturbances, dizziness, and flu-like symptoms; Potassium Chloride is used to treat blood pressure issues and a lack of potassium may cause muscle weakness, irregular heartbeat, mood changes, or nausea and vomiting; and Furosemide is used to treat fluid retention and swelling caused by congestive heart failure and other conditions and should only be taken as directed by the patient’s doctor.

Regarding the allegation of lack of staffing: It was alleged residents were left in their chairs in the same positions for extended periods, wellness checks are not being conducted, and residents’ food intake is not being monitored properly resulting in weight loss. LPA interviewed AD who denied the allegation and stated that the facility has been using staffing agencies to fill in any staffing gaps since 2020. When interviewed, the Wellness Director denied the allegation and stated that staffing at the facility is based on a system which calculates how many service hours are required daily by the care plans of the residents and determines the number of staff needed. For example, on 08/23/23, the staffing schedule was 3 caregivers and 1 medication technician for the morning shift, 2 caregivers and 1 medication technician for the afternoon shift, and 3 caregivers and 1 medication technician for the overnight shift, with the Wellness Director, Wellness Coordinator, and Residential Care Coordinator also scheduled. Staff interviewed stated that based on their care plans, not all residents receive wellness checks. Residents are able to use their pendant to call for assistance. Residents who have difficulty using the pendant are scheduled for regular wellness checks. LPA reviewed weight records for 10 residents which show that residents’ weight is closely and regularly monitored by the facility and that 2 residents lost enough weight to trigger warnings in the facility system and 1 of these residents has already regained weight.