Complaint Investigation Report

On 08/28/2023, LPA conducted an unannounced initial complaint visit to the facility above. LPA conducted thorough observation of each resident room including the room of R1. LPA also observed all storage areas in each resident bedroom as well as storage areas in the common areas of the facility such as cabinets, drawers, closets, storage room(s), etc. During the initial complaint visit on 08/28/2023, LPA did not observe bungee cords of any kind anywhere in the facility. LPA has frequently visited the facility including the dates of 07/18/2023, 08/14/2023, 08/28/2023, 10/12/2023, 12/05/2023, and 01/04/2024. At no point during any in-person visit to the facility by LPA were any bungee cords observed within the facility nor were any signs of trauma to R1’s wrists observed by LPA while R1 was in the facility. On 08/31/2023, LPA interviewed a Staff member from a Hospice Agency who had frequent contact with R1 on at least a weekly schedule within the past few months. Witness #1 (W1) stated that there was only one (1) individual who had allegedly observed all the allegations, and that W1 has been to the facility numerous times in the past few months and had not seen anything close to what the allegations are describing. W1 stated to LPA that they had visited the facility many times before with no concerns noted. LPA also spoke with other Staff from the Hospice Agency who have been into the facility in the recent months and no Staff member could corroborate seeing anything like what the allegations are describing. W1 was surprised to hear what the allegations described, as they have been in the facility on a consistent basis in recent months with no concerns regarding any restraints. According to W1, they went to see R1 on the afternoon of 08/24/2023, with no bungee cords seen in the resident's room. W1 checked the drawers in R1’s room and checked the closet but could not find any bungee cords at all. W1 stated to LPA that they had never observed signs of trauma to R1’s wrists or had any concerns with the care of R1. Other Hospice Agency Staff interviewed by LPA stated that R1 occasionally needed prompting and redirecting of negative behaviors such as lashing out and being upset at being woken up. However, they had never observed or heard of any Facility Staff members using any type of physical restraints on R1 or that R1 would self-harm. On 08/28/2023 and 10/12/2023, LPA interviewed Staff members of the facility about the allegation. No Staff member of the facility stated that any bungee cords were used on R1 at all. Staff members stated that R1 was on Hospice Care, medicated, and never physically restrained with anything. All Staff members interviewed stated that they did not restrain R1 with bungee cords to prevent R1 from committing self-harm. On 08/28/2023, LPA conducted record review of facility documentation for R1. Records reviewed for R1 included the Centrally Stored Medication and Destruction Record kept by the facility for all residents in care, physician’s notes for R1, Resident Appraisal for R1, Statements of Patient Advocates or Ombudsman, Physician Orders for R1 including Primary & Secondary diagnosis, Appraisal Needs & Services Plans (ANS), Physicians Reports for Residential Care Facilities for the Elderly (RCFE), and Emergency Information. Continued on 9099-C