Complaint Investigation Report

As they began to assist R1, they drank 3 glasses of liquid and ate all of their food. This complaint does not have specific allegations about the food or service provided by the dietary department, rather that there were not sufficient staff to assist R1 with their meals resulting in weight loss. R1 later moved to a 6-bed facility. LPA interviewed R1’s hospice nurse who stated that R1 has had a documented weight gain since being at this new facility.

LPA interviewed staff who acknowledged that there are typically 3 caregivers in the morning and evening shifts along with a med tech scheduled. NOC shift typically has 2 caregivers and one med tech scheduled. LPA reviewed the facility’s census for the months of July, August, and September 2023. LPA reviewed staffing schedules vs. timecards for July 27, 2023 where the complainant alleged that there was insufficient staffing. LPA found that there were 2 caregivers and one med tech for the morning shift. The census this date was 37 residents. Upon review of timecards, LPA found that there is a pattern of less than stated staffing during weekends. According to staff interviewed, management often found it difficult to find replacements when staff were unable to work their scheduled shift. Additionally, staff stated that management would rarely help staff with residents when they were short staffed.

Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

LPA previously cited the facility for insufficient supervision and lack of staffing on 12/6/2023 for complaint control # 59-AS-20231003164146. Due to the timeline of when this complaint was received and completed, although the allegations are substantiated, there will not be any citations given.

Exit interview conducted. A copy of this report was left at the facility.