Complaint Investigation Report

Executive Director, Inan Linton stated R1 was non-weight bearing with full assistance of activities of daily living, when released from a skilled nursing facility to their facility. ED Linton also stated R1 was not a two (2) person assist but needed assistance with either a stand/sit or Hoyer lift device. However, R1’s Preplacement Appraisal dated 03/03/21, signed by ED Linton indicated R1 required assistance with transfers, bathing, dressing/grooming, moving about the facility, toileting, and medication management. The appraisal does not address two (2) persons assist. R1’s Physician’s Report dated 02/19/21 indicated R1 was bedridden and required assistance with all activities of daily living. Staff interviews revealed R1 was not two (2) persons assist. Staff stated R1 used a walker and would walk around their room and go to the bathroom on their own. Staff also stated R1 required assistance with going to the bathroom for safety reasons. According to statements made by staff, they were not following the facility’s Assessment and Service Plan dated 03/03/21, which required transfer assistance by two (2) staff members for R1.

It was also alleged staff did not respond to resident in a timely manner. Outside source interview revealed R1 had to wait over 30 minutes, and up to 45-50 minutes to get help with the bathroom. A review of R1’s Response Time document, also known as Call Button Log dated 03/04/21 thru 03/31/21 indicated multiple responses over thirty (30) minutes. On 03/05/21 response time 45 minutes 52 seconds; 03/06/21 response time was 1 hour 30 minutes; 03/08/21 response times were 42 minutes 7 seconds and another for the same date of 51 minutes 35 seconds. On 03/11/21 response times were 33 minutes 50 seconds and another for the same date of 40 minutes 8 seconds. On 03/18/21 response time was 31 minutes 55 seconds; 03/27/21 response time of 32 minutes 19 seconds; and 03/30/21 response time 59 minutes 5 seconds. Staff interviews confirmed some staff did not respond timely due to not wanting to assist residents. Resident interview confirmed late response times and having to sit in soiled diapers until the NOC shift arrived as staff came within 24 hours to check on residents during that time frame. Continued on an LIC 9099C.