Complaint Investigation Report

Allegation - Staff not administering resident's medication as prescribed. - Unsubstantiated.

The Department interviewed facility staff, residents in care, and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) physician’s report, appraisal/needs and services plan, medication list, physician’s orders, medication administration records (MAR). The Department reviewed R1’s medication records for January 2022- October 2022. Medication records indicated, R1 did not receive medication Quetiapine on 7/31/2022. According to physician’s order, Quetiapine is to be given 1 tablet by mouth everyday at bedtime. Interview statement received from administrators, Nellie and Stephanie, indicated R1 was receiving all of R1's medication. R1 has never refused medication. Administrator Stephanie stated Quetiapine was given to R1 but administrator forgot to sign off on the medication log.

The Department interviewed a total of 2 residents in care. Interview statement received from residents indicated staff are consistently assisting residents with their medications. The Department conducted medication count for two (2) residents in care. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for 2 residents and found no discrepancies. Complaint was filed against the facility on 3/21/2023. The Department was unable to conduct R1's medication count with the facility for R1's July 2022 medications. The Department is unable to determine if medication was provided to R1.

Allegation - Facility does not have enough staff to meet the needs of residents in care. – Unsubstantiated.

According to interviews conducted, there is one (1) staff per nine (9) residents. The Department requested and reviewed R1’s physician’s report, appraisal, and service plan. According to R1’s physician’s report, R1’s primary diagnosis is Dementia. R1 has bowel, bladder, and motor impairment. R1 needs assistance with bathing, dressing/grooming, feeding, toileting, and medication.

According to personnel Report (LIC 500), the facility staff consists of two (2) administrators and three (3) caregivers. Interview received from administrator, Stephanie Reid, indicated there are 2 caregivers working from 6AM to 6PM and 1 staff working from 6PM to 6AM. Interview statement received from administrator, Nellie Johnson, indicated that R1 needed 1:1 care and the facility had provided that for R1. Administrators are the ones who are providing care to residents with higher level of care. R1 had a change of condition. R1 was receiving wound care by a specialist for bed sore. Bed sore was healing. The main concern was that R1 was bending over while using the bathroom and the wound. Administrator contacted R1’s PCP due to R1 having muscle stiffness. PCP notified administrator the cause of R1 bending over is due to neurological or from nerve. Administrator provided records of the facility’s communication with R1’s RP.