Complaint Investigation Report

On 12/16/2023, R1 had a witnessed fall at approximately 3:00pm. At 3:45pm, the facility called POA and left a message. The facility's alert charting dated 12/16/23, 8:49pm stated that the POA was contacted and did not want R1 to be transported by ambulance. POA wanted to be updated should anything change. At 11:04pm the facility alert notes confirmed that R1 was sent out to the ER were R1 was admitted at 9:43am and the diagnoses was a rib fracture. Civil penalty assessed.

Allegation: Staff do not have the required training. Based on records reviewed and interviews with staff the facility did not reorder medication prior to R1 running out of medication causing R1 to without two medications for seven days from 9/14/2023 until 9/21/2023. The facility attempted to get the medications for R1 via faxing request to the Primary Care Physician. However the information was not confirmed to be ordered by the PCP until the 9/21/2023. This is a training issues and supports the substantiated allegation.

Allegation: Staff did not give resident medication. Based on records reviewed and interviews with the staff the facility was out of 2 medications for R3 from 9/14/23 to 9/21/23. Substantiated.