Complaint Investigation Report

Based on interviews conducted during this investigation, it was learned that there were two primary phones being used in the memory care unit at this time. It was learned that one land line was located in the medication room and the other was in the office for the Activities Director.

It was learned that there was not a direct line to the memory care unit and all calls were forwarded over from the front desk in the Assisted Living side.

It was learned that memory care staff did not have direct access to the phone lines in the medication room and office of the Activities Director. It was learned that memory care staff only carried a mobile device used to communicate and receive notifications from the front desk. They were not tasked to answer or return calls from this land line in the medication room.

It was learned that the medication technician only had access to the phone placed in the medication room but had other tasks and duties related to handling, dispensing, and documentation of the resident medications that took priority while on duty.

It was learned that, if time permitted, the medication technician would be able to return any missed calls and voice mails at a later time during their shift.

It was learned that the only other land line for the Activities Director was only accessible to this particular individual in their office. Memory care caregivers and medication technicians did not have access to receive, retrieve, or return any phone calls at this time from this particular office land line.

Based on a review conducted for a physical plant review, it was observed that there were (4) individual doors located throughout this facility which had a press pad which could be used to activate and open the doors automatically leading out into the courtyard at this time.

It was observed that the only door that was functioning when the press pad was activated was the door directly outside of the Assisted Living dining room. The interior pad and exterior pad, when activated, did automatically open the door at this time.

It was observed that north facing door with its press pad, when activated, did automatically open the door but only functioned properly when activated from the interior. It was observed that the exterior pad was not functioning at this time when activated to automatically open up the door.

It was observed that the fireside room exit door, with its interior press pad, was not functioning at this time.

It was observed that the exterior press pad for the exterior door leading into the bistro area was also not functioning at this time as well.