Complaint Investigation Report

Regarding the allegation of- facility did not assist resident with self-administration of medication as prescribed, the reporting party stated that the facility failed to assist Resident #1 (R1) with pain medication as ordered by the physician.

According to Staff #3 (S3), R1 asked for pain medication in the middle of the night, and S3 did not feel comfortable of given it to R1 so S3 asked R1 to wait for S2 to give it in the morning as S2 was sleeping at the time.

According to R1's hospital medical record, R1 has an order for Acetaminophen (Tylenol) every 6 hours as needed for pain. During an interview with S2, S2 stated that facility did not give R1 any pain medication during the time of R1's stay.

Based on interviews and record review during the course of investigation, this allegation is substantiated as the facility did not give R1's pain medication as prescribed by the physician.

Regarding to allegation of- staff did not regularly observe resident for change in condition, the complainant reported that the facility did not observe and check R1's blood sugar level as ordered by the physician which resulted R1's blood sugar rose to 282.

According to Administrator, the facility did not conduct a pre-admission appraisal of R1 prior to R1's admission, therefore, the facility was not aware that R1 required blood sugar checks every 4 hours and then insulin injections accordingly until R1's responsible party informed the facility of such needs after R1's admission.

In addition, the facility failed to conduct a pre-admission appraisal to ensure R1 is suitable for the facility. Furthermore, during the course of investigation, LPA observed injections and blood sugar finger stick checks for the resident who was not capable of performing it by themselves were administered by a facility staff who was not a skilled professional . These deficiencies will be cited on LIC809 and LIC809D.