Complaint Investigation Report

did not reveal purchases of bologna. A review of C1’s food log revealed the facility began tracking C1’s food and beverage intake on 04/21/2022. C1’s food logs dated 05/25/2022 and 06/12/2022, did not note C1 had an 8oz glass of milk during breakfast time as prescribed. However, per interviews with staff, C1 was offered milk but declined it. A review of a Physician’s order dated 03/24/2022 read C1 is to be given one “Gatorade” at lunch. Interviews and food logs revealed C1 was given Body Armour drinks instead of Gatorade, on more than one occasion. Per the licensee the switch was made due to the facility staff having concerns about the vitamins, hydration, and sugar content of the Gatorade versus Body Armour. However, it was revealed facility staff did not consult with the doctor prior to making the switch. The licensee reported they thought C1 only had to have an electrolyte enhancing drink not a specific brand. The allegation is therefore Substantiated.

Regarding the allegation of failure to report an incident involving a resident , interviews with a witness indicated C1 was taken to the emergency room on 04/07/2022 by an approved individual other than facility staff. Interviews further revealed, when C1 returned to the facility on this same day, facility staff were verbally told C1 was taken to the emergency room and that home health services were going to be needed. Facility staff interviews corroborated they were aware of the emergency room visit. Facility staff interviews also revealed home health visited on 04/27/2022, 04/29/2022 and 05/11/2022. The licensee indicated they were unsure if they should report, as they were not the ones that transported C1 to the emergency room. A facility file review was conducted and there was no SIR submitted for C1’s emergency room visit and home health visits. Therefore, this allegation 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 where a copy of this report, and appeal rights were reviewed and provided to Licensee, Brittany Brittany Wardle- Lavenant.