Complaint Investigation Report

Regarding the allegation that staff did not provide proper medication assistance to resident in care: it was alleged that R1 did not take their medication because staff would leave R1’s room without confirming they took the medication. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed five residents and did not obtain information corroborating that medication technicians leave residents’ rooms without confirming residents have taken their medication. However, LPA reviewed R1’s care notes which indicate on May 12, 2021, a reminder was documented for the medication technicians emphasizing the importance of staying in the room and watching R1 drink a liquid medication, advising that R1 missing doses of this medication will alter R1’s potassium levels, and advising that on May 12, 2021 R1’s family reported that R1’s dialysis nurse found R1’s potassium levels to be dangerously high. In addition, LPA reviewed R1’s MAR which indicates R1’s Sevelamer Carbonate 800MG was not documented as being given for the noon dose on January 24, 2022.

Regarding the allegation that a resident's call button was in disrepair: it was alleged that R1’s call button was not functioning for three weeks in January 2022. LPA reviewed the facility’s internal communications which document that the entire call system stopped functioning on February 16, 2022, and checks were conducted on all residents in lieu of the call system. However, per the facility’s’ internal communications, on February 17, 2022, a caregiver checked on R1, R1 complained that they had been calling for assistance, but the caregiver documented that the call light system was still not working and they had only checked on R1 because of their rounding. R1’s care notes and the facility’s internal communications do not document any issues with the call button system after February 17, 2022. Facility staff were supposed to conduct regular checks on residents while the call system was not working, but the information obtained shows that R1 was calling for assistance for an unknown length of time, the caregiver did not receive the signal or respond timely, and the caregiver only checked on R1 as part of their last check without realizing R1 had been calling for assistance.

Regarding the allegation that facility did not maintain grab bars for each resident toilet: it was alleged that R1’s room did not have grab bars for the toilet and staff did not correct the issue. Per the facility’s resident roster and R1’s MAR, R1 resided in Room 165. LPA interviewed the facility’s maintenance director who stated there are two styles of bathrooms, where the old style has a sink that goes up to the toilet and the sink can be used as a grab bar, and the new style where the sink is far from the toilet and cannot be used as a grab bar. Per the facility’s maintenance director, grab bars are installed when requested by residents’ families.