Complaint Investigation Report

Regarding the allegation that a resident was not allowed to use the telephone: it was alleged that on October 9, 2024, R1 requested to use a telephone, facility staff told R1 “we don’t have the legal authority to let you use the phone”, R1 protested, and R1 was eventually allowed to use a telephone two hours later. LPA interviewed AD and MCD who denied the allegation, stating that R1 was allowed to use the telephone whenever they wanted and would use it often to call a family member. Regarding the alleged two-hour delay on October 9, 2024, AD and MCD stated that immediately after R1 requested to use a telephone, another resident had a serious fall in the garden which required 911, R1 was advised that once the emergency was resolved staff would be available to assist R1 to use a telephone and R1 agreed without complaint, and once the emergency was resolved and staff were available to assist, R1 was immediately assisted to use a telephone less than forty minutes after R1 had originally requested to use a telephone. LPA reviewed an Unusual Incident Report dated October 10, 2024, which corroborated that a serious fall occurred on October 9, 2024, which required 911 at the same time R1 requested to use a telephone. LPA requested the facility’s telephone logs, but was advised by MCD that the facility does not log phone calls made by residents. LPA reviewed R1’s Care Notes dated September 9, 2024, which documents another recent call between R1 and a family member and per AD the facility does not document all calls residents make and R1 makes calls to their family member frequently. LPA interviewed R1 who stated that this is the only incident involving access to a telephone and that R1 was provided access to a telephone shortly after requesting it. LPAs interviewed 20 residents who did not provide information corroborating that the facility is not providing residents access to a telephone when requested. The information obtained did not corroborate that the facility denied R1 use of a telephone or intentionally delayed assisting R1 to use a telephone.

Regarding the allegation that the facility did not respect residents visitation wishes: it was alleged that on October 9, 2024, the facility allowed two family members to visit R1 at the facility, R1 reacted violently and did not want to see these family members, and R1 had previously made their wishes known to the facility that they did not want these family members to visit R1 at the facility. LPA interviewed R1, who has cognitive and mental health diagnoses, who stated that they told the facility from the very beginning that they did not want any visitors except one specific individual and that their visitation wishes were violated on October 9, 2024, but could not remember any other violations of their visitation wishes. LPA interviewed one witness, R1’s family member, who corroborated R1’s statement and stated that the facility allowed visitors against R1’s wishes multiple times.