Complaint Investigation Report

Interview with the Executive Director (ED) indicated that the facility put in place a temporary plan of care for R1 requiring staff to conduct hourly checks due to the possibility that the call button pendants were not functioning properly in the memory care unit of the facility. Email correspondence between the ED and R1’s responsible party, dated 8/28/23, indicated that the facility will immediately begin conducting hourly checks on R1 until the facility is able to have a diagnostic check conducted on the emergency call button system. The ED indicated that a sign-in sheet was created to log the hourly checks and staff were instructed that it is necessary for them to record their hourly checks.

Interviews conducted with staff (S1 & S2) indicated that care staff are to conduct hourly checks on R1 and fill out the log for the time the check was completed. Interviews also indicated that neither S1 nor S2 were aware of any care staff pre-filling the log before completing their hourly checks. Interview with S2 indicated that the hourly checks were a part of R1’s ADL/care plan until R1 moved out of the facility. According to R1’s care plan dated November 2023, R1 is to have status checks conducted 24 times per day.

The facility provided the Department with the hourly check sign-in logs dated 8/28/23-9/18/23. There were several entries that were missing from the provided logs. Between 8/29/23 at 9:30pm to 8/30/23 at 2:30pm, there were no records of staff conducting hourly checks on R1. Between 9/1/23 at 5:30pm to 9/2/23 at 12:00pm, there were no records of hourly checks conducted. On 9/2/23, there were no entries between 6:12pm-10:40pm. On 9/3/23, there were no entries between 5:45am-7:05am, as well as 8:16am-10:20am. On 9/8/23, there were no entries between 12am-5am. On 9/11/23, there were no entries between 12pm-1pm. On 11/7/23, LPA conducted a visit at the care home and requested the facility provide documentation for the missing entries on the hourly check log. LPA was informed that the facility does not have any additional documentation to provide.

According to the facility’s Emergency Response Systems Policies and Procedures dated October 2014, the care providers in the care home carry pagers. “When an alert is received on the pager the care provider will note if the alert is coming from one of their assigned residents and respond to the alert. If the care provider cannot promptly answer the alert because he/she is attending to another resident and cannot safely breakaway to answer the alert, the care provider will utilize their radio to request that another available care provider respond to the alert. The available care provider will acknowledge the request”.

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