Complaint Investigation Report

Based on interviews and records reviewed it was determined that R1 discharged from facility and medications have been removed from facility per regulations and facility protocol. Orders reviewed matched medication logs reviewed. Medication logs indicated that medications prescribed to R1 were given as ordered, and no additional medications given based on record reviews and interviews. As a result, there is not a preponderance of evidence to conclude if facility ever gave wrong medications to R1 based on documents reviewed and interviews conducted. Therefore, this allegation is UNSUBSTANTIATED.

Allegation #2: Non-skilled professional is administering insulin injections. Allegation stated a non-skilled professional administered insulin to R1. LPA interviewed Administrator, S1, S2, and S3. LPA also interviewed registered nurse from nursing registry and registered nurse from home health agency. Additionally, LPA reviewed medication log sheets for R1 dated January to March of 2022, Physician orders for R1 and board of registered nursing documents. Based on record reviews, it was revealed that currently licensed nurses administered insulin to R1 per physician orders as indicated by signature on medication log sheets. Based on interviews conducted, there was no observation of any non-skilled professionals administering insulin to R1. As a result, there is not a preponderance of evidence to conclude that a non-skilled professional ever administered insulin to R1, therefore this allegation is UNSUBSTANTIATED.

Allegation #3: Facility is not ensuring resident receives meals. LPA interviewed Administrator, S1, S2, and S3. LPA also conducted a mealtime observation on 4-21-22 and reviewed facility menu. Allegations states that R1 did not receive a meal at least 3 times. Based on interviews and record reviews it was determined that R1 was offered meals regularly and based on a modified menu for R1’s diabetic diet with occasional refusals; resulting in later than normal mealtimes. Based on observation by LPA it was determined that facility was appropriately staffed in the dining room and serving residents in care timely and according to the current menu. Observation by LPA also determined that special requests by residents were honored. Based on the interviews conducted, records reviewed and observation, there is not a preponderance of evidence to conclude that facility did not ensure meals for R1. As a result, this allegation is UNSUBSTANTIATED.