Complaint Investigation Report

staff S2 indicated that a call was made to R1’s POA when this occurred and that any time there was any adverse reaction or behavior with R1. S2 indicated that they have made those calls and indicated that R1’s POA is very involved with the care of R1 and therefore staff are very mindful of always providing information to POA.

It is alleged that staff left resident in soiled diapers for an extended period of times. LPA conducted a site visit on June 10, 2024, and was unable to make observations to R1 as R1 had moved out of the facility May 01, 2024. Interviews with 1 of 2 staff indicated that R1 could get very combative at times and did not allow for staff to give R1 proper care until R1 would calm down. Based on the information available through record review and interviews, LPA is unable to corroborate or refute that a violation occurred as alleged as the information collected is conflicting.

It is alleged that staff overmedicated resident. Records review MAR for January – May 2024 indicates that medication was given to R1 as indicated in prescription directions. MARs reflect that medication was given at the scheduled time per order indications. Interview with 1 of 2 staff revealed that medication is given as prescribed and there is no way staff can over medicate because that would cause a shortage on dosage that was needed for R1 to be given dosage as indicated per day. Staff indicated this would reflect on MAR, but however dosages are signed off as given as indicated on prescription instructions.

It is alleged that staff did not notify authorized representative of new medication. Records revealed copies of doctor’s orders for medication on file for R1, and a completed MAR sheet for all medication for resident. Interview with 2 of 2 staff revealed that they would inform POA of anything that involved R1’s care. POA was very involved with residents’ care therefore staff at facility kept POA informed of care. Staff indicated that once ordered are received by the physician the medication is given according to the physician's directions. Based on the information available through record review and interviews, LPA is unable to corroborate or refute that a violation occurred as alleged as the information collected is conflicting.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.