Complaint Investigation Report

Furthermore, staff provided regular care, including meal assistance, neighborhood walks, and the use of two staff for showering due to R1's tendency to kick. Administrator Sally Wong also provided insight, stating that R1's weight loss concerns were discussed with a physician, who acknowledged that weight gain might take some time. R1 had regular medical follow-ups, including a visit on 6/17/24 where unintentional weight loss was addressed. Interviews also revealed that R1's appetite was noted to be good. Further, no seizure history was reported by R1's family or medical records prior to moving to this facility. Record review indicated that an incident of seizure occurred in 9/13/24, which was addressed with medical intervention, including emergency transport and seizure medication. Record reviews corroborated these findings, confirming that R1’s weight remained stable, with minor fluctuations documented in facility records.

While a seizure incident occurred on 9/13/24, there was not enough evidence to indicate that staff failed to respond appropriately, as the incident was followed by prompt medical consultation and emergency action. Additionally, R1’s physician prescribed dietary adjustments, including prescribing ensure to address weight loss and medication to address seizure management. Based on the information gathered, the facility and staff took measures in addressing R1’s needs, including medical consultations, ongoing support with mobility and feeding, and response to a change in condition (seizures and weight loss), therefore, this allegation was UNSUBSTANTIATED.

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The investigation into the allegation that staff did not meet R1's nutritional needs consisted of review of records and interviews with staff. Staff members (S1, S2, and S3) confirmed that R1 had a good appetite and that they assisted with meals, including chopping food to accommodate R1’s lack of teeth. It was also noted that R1 was on a special minced and moist diet due to dysphagia. Administrator Sally Wong further corroborated that R1's appetite was consistently good, and R1 ate the same amount as the other residents.

Additionally, R1's physician reports indicated that R1 had a stable weight range since admission, with minor fluctuations. At the time of admission, R1’s weight was recorded at 79 lbs, and throughout their stay, it remained relatively stable, reaching 80 lbs by 6/7/24. Concerns regarding R1’s weight were addressed in a timely manner, and on 9/23/24, after a blood test, R1 was prescribed Ensure supplements to help with weight gain. While R1 experienced unintentional weight loss, this was managed with medical guidance, and R1's doctor did not attribute this to any issues related to the facility’s care.