Complaint Investigation Report

Based on review email communications, care progress notes, and interviews, it was indicated facility staff were in communication between R1’s regional center representative and physician between the dates of 3-12-24 and 4-23-24 to address elevated lithium levels and incontinent issues which included referrals to urology and endocrinology. Furthermore, it was revealed that medical needs were addressed on R1’s IPP and functional capabilities assessment. Interviews conducted revealed facility staff have addressed R1’s changes in condition and did not reveal any corroborated statements to counter this claim. As a result, there is not a preponderance of evidence to conclude staff did not address resident’s changes in condition, therefore, this allegation is UNSUBSTANTIATED.

Allegation: Staff does not ensure resident has appropriate clothing. LPA conducted interviews, record reviews, and facility observation as noted above. Based on observation conducted on 5-9-24, it was revealed R1 had in possession various clothing in adequate amounts and as appropriate for various seasons. Interviews conducted and professional progress notes further revealed R1 wears “loose flowy clothes…” as a matter of choice. Furthermore, interviews conducted did not reveal any corroborated statements of staff not ensuring appropriate clothing for residents in care. As a result, there is not a preponderance of evidence to conclude staff did not ensure appropriate clothing for residents during various periods of residency, therefore, this allegation is UNSUBSTANTIATED.

Allegation: Staff are not meeting resident’s toileting needs. LPA conducted interviews, facility observation, and record reviews as noted above. Based on review of R1’s toileting log sheets dated April-May 2024, it was indicated facility staff have documented consistently, and were instructed to check R1 every half hour to ensure monitoring for incontinent needs which included indication of type of care performed as needed. Interviews conducted did not reveal any corroborated statements of staff not meeting a resident’s toileting needs. Email communications between facility, regional center, and R1’s physician indicate an attempt to address incontinent care needs. Facility observation conducted did not reveal malodorous environments or visual evidence to indicate a lack of toileting care. As a result, there is not a preponderance of evidence to conclude staff are not meeting resident’s toileting needs, therefore, this allegation is UNSUBSTANTIATED.