Complaint Investigation Report

The LPA reviewed the Medication Administration Record (MAR) and confirmed that the medication was provided to R1. The LPA was not able to interview R1 due to being removed from the facility.

Allegation 2: Staff did not notify authorized representative of change in condition:

The complaint details indicate R1 began hallucinating on 2/6/22 after reporting that they witnessed two staff members standing in the doorway of their room. R1 was on a FaceTime call with family and the family member was able to confirm that no one was standing in the doorway. Staff 1 (S1), Staff 2 (S2), Staff 3 (S3) and Staff 4 (S4) denied witnessing R1 hallucinating. R1's file review confirms that R1 was not diagnosed with hallucination as a change of condition. The executive director confirmed that R1 did not have a change in condition. The LPA was not able to interview R1 due to being removed from the facility.

Allegation 3: Resident missed medication:

On 8/20/21, R1 noticed that Staff 4 (S4) did not have Medication 2 (M2) during the medication pass. S4 retrieved the medication and provided it to R1. The Power of Attorney (POA) for R1 confirmed this information as accurate. The LPA reviewed the Medication Administration Record (MAR) and confirmed that the medication was provided to R1. The LPA was not able to interview R1 due to being removed from the facility.

Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore all three allegations are UNSUBSTANTIATED at this time.

An exit interview was conducted where this report and LIC 811 were provided to the executive director.