Complaint Investigation Report

has dispensed and that the resident has received medication as prescribed by the physician. According to training received by facility staff; When staff arrive for their shift, the staff is to review the MAR sheet, and both the arriving and departing staff should sign off acknowledging that the MAR sheets are accurate. However, LPA found that there were several times where staff reported signing upon arrival for their shift and the departing staff had already signed, noting a discrepancy and a false claim. Therefore, the allegation Staff are falsifying facility's records is SUBSTANTIATED.

The allegation noted above was investigated by the Department; Facility documentation were reviewed, and interviews were conducted; the following was revealed; Upon reviewing Resident #4 (R4) file, prescription notates that R4 can have Baclofen three times a day as needed. However, on the Medication Administration Records (MAR) sheet, documents that R4 can only have the medication once a day. R4 also had a prescription for an antibiotic that was written on January 2, 2021, and as of January 6, 2021, R4 had not received the prescribed medication. Staff explanation was that they were too busy to fill the prescription; the staff’s employment was subsequently terminated soon after this information was revealed. As a result, the facility staff failed to dispense medications as prescribed by physician. The allegation of medications are not given as prescribed is SUBSTANTIATED.

Resident(s) toileting needs not met-Left sitting/laying soiled clothing.

LPA reviewed pertinent documents and conducted interviews with staff that indicated that they were not comfortable with things that were happening at the facility such as the overnight staff allegedly sleeping for the most of their shift. Such as sleeping instead of checking on resident’s is a contributing factor of the residents not being changed. Per feedback provided from staff interviews; Staff were reporting for their shift, the call button would be going off, would conduct their initial checks and would find as many as three residents completely soiled in their urine or feces or both. Therefore, the allegation of Residents toileting needs not met-Left sitting/laying soiled clothing Is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.