Complaint Investigation Report

Upon a further review of R1's facility file, there were not any documents for LPA to review such as Emergency ID Sheet, Admission Agreement, Physician’s Report, Needs/Services, Plan Functional Capabilities, or any Assessment Forms. During today's visit LPA observed for three (3) reviewed files out of (38) resident files to have the required documentation. Based on record review the allegation of staff does not ensure residents records are properly maintained is SUBSTANTIATED.

Resident is left in soiled adult brief for an extended period of time

Per the Business Office Manager/Med Tech Vanessa the incontinent residents are checked every two hours. Interviews conducted with residents revealed that sometimes it is impossible to be checked every two hours but, that when assistance is needed whether calling on the telephone or using their pendant/call button staff responds right away. The Nurse visit notes from an outside agency revealed that R1 had skin irritation believed to have been caused from being left in a soiled brief. Further interviews conducted with facility staff revealed that yes, there are residents that are left in a soiled adult brief and it is usually occurs during shift change, and that staff are reported to ignore the resident call lights. Based on interviews and records review the allegation of resident is left soiled in an adult brief for an extended period of time is SUBSTANTIATED.

Staff does not ensure discontinued medications are properly discarded

During a complaint visit conducted on 08/01/23, LPA conducted a review of R1's medication as well as the Medication Administration Record (MAR) and observed for a medication to have been finished on 7/28/23, however the medication was was still in R1's basket. During today's visit LPA observed for R2 to have medication in their basket that was not on the physician's order. LPA was informed that R2 was admitted to the facility with that medication. R2 was admitted to the facility on 08/04/23. Per Business of Manager/Med Tech Vanessa the medications are disposed of by the facility Nurse, and is done as needed. Per Vanessa the facility Nurse comes to the facility two(2)- three (3) times per week. Based on observations and records review the allegation of staff does not ensure discontinued medications are properly discarded is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted and a copy of this report, and appeal rights were provided to Robin Rebollar-Icamen.