Complaint Investigation Report

Records reviewed confirmed that the facility does not have a 30 day assessment for R1 nor a behavior intervention plan. The information reviewed was a laminated 8'11" paper titled" Precursor Behavior Worksheet " and inconsistent data collection for all residents in care.

R1 has had multiple incidents and/or visits to the emergency room here is a list of the events: incident on 2/8/2024(medication error), ER visit 2/17/2024 (Admitted for vomiting blood and was discharged on 2/26/2024), incident 3/1/2024 (for aggression toward other consumer and staff), ER 3/4/2024 (Self injurious behavior) and ER 3/22/2024 (vomiting).

The discharge papers confirmed that R1 was to be seen by their primary care physician and/or other doctors for follow-up after the ER visits. The facility does not have follow-up information from any of the discharges for February or March.

R1 has multiple deliberate self harm scars from a history of self injurious behaviors and on today's visit, R1 had fresh skin breaks that caused bleeding on his hands, in his mouth around the teeth and gums. R1 has missed medications and is not eating regularly.

The facility staff is missing required training for each residents as it pertains to updated intervention plans and daily (consistent) behavior documentation for each resident.

As a result of this investigation the department finds this allegation to be SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations