Complaint Investigation Report

THIS IS AN AMENDED VERSION OF THE ORIGINAL REPORT TO REMOVE ALLEGATION #3.

LPA Lee also interviewed three facility staff, all of whom denied the allegation and stated that Resident 1 (R1) had a physician’s order authorizing the use of a blanket and a wheelchair safety belt for R1’s safety. An interview with an outside agency indicated that they had not observed any residents being restrained. Additionally, an interview with R1’s responsible party revealed no concerns regarding the allegations, abuse, or neglect by facility staff. A review of records showed that R1 was placed on hospice care and that a physician’s order was in place authorizing the use of a floating blanket system for bed safety and a wheelchair safety belt to provide protective postural support. Based on the interviews conducted and the records reviewed during the investigation, LPA Lee was unable to corroborate the allegation.

It was alleged that staff were chemically restraining residents in care. This investigation consisted of interviews with staff, residents, and an outside agency, as well as a review of records. LPA Lee interviewed three of three residents, all of whom stated they had no concerns regarding their medications and reported that medications are administered by facility staff. LPA Lee also interviewed three facility staff members, all of whom denied the allegation and stated that medications are administered in accordance with physicians’ orders and that no residents are chemically restrained. An interview with an outside agency indicated no concerns regarding residents’ medications. A review of medications was conducted for five out of five residents by examining the medications stored in each resident’s medication box. The review indicated that all medications present were prescribed by a physician. During records review, it was learned that the facility was not consistently or accurately documenting medication administration on residents’ Medication Administration Records (MARs). Additionally, the facility was not properly maintaining centrally stored medication destruction records; however, no evidence was identified to indicate that medications were administered for the purpose of chemical restraint. It was also learned that Resident 1 (R1)’s medications were removed from the facility by hospice following R1’s death and were therefore unavailable for review. Based on R1’s MAR records it indicated that R1 was receiving R1 medication as it was initialed given for the month of June 2025 to November 2025. Based on the interviews conducted and a review of available records, there was insufficient evidence to support the allegation that staff are chemically restraining residents in care.