Complaint Investigation Report

the process quicker. This would eventually lead the staff person to raise their voice in further attempts to gain assistance from the resident.

It was learned that this type of treatment, verbal and physical, from the attending staff person left the residents feeling intimidated, stressed, and mistreated.

Based on interviews and the evidence that was gathered throughout the course of this investigation, it was learned that facility staff were required to acknowledge and respond to the call buttons once activated by the residents. It was learned that these types of call button activations ranged from requiring assistance in toileting, transferring in/out of bed, or flat out emergencies from falls or injuries. It was learned that facility staff were required to respond as quick as possible since it was unknown as to the reasons for the call button activations and facility staff persons were to never exceed a response time of more than 10 minutes.

It was learned that all call button activations were monitored and recorded upon initial activation up until the responding staff person was able to properly reset it in the residents room or personal pendant.

Based on a review of the facility call logs obtained for the months of August 2023, September 2023, and October 2023 it was learned that there were a total of 1,156 call button activations in the Memory Care unit of this facility. Of those 1,156 call button activations roughly 176 were responded to by facility staff but those responses were all in excess of 10 minutes or more. This equated to a 15 percent response time by facility staff that were in excess of 10 minutes or more.

It was learned that in that time span there also were documented response times that even exceeded the one hour mark as well.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated Administrator at this time.