Complaint Investigation Report

Regarding the allegation of staff speaks inappropriately to resident, RP stated that staff (RP doesn't know names) always screams at R1 "when staff wants the resident to comply”.

According to a staff member S2, there’s a staff who is an excellent staff member (S3), but sometimes speaks loudly, doesn't yell, but it comes across as yelling, but just speaks very loudly. S3 is never saying anything demeaning or punitive or anything, S3 is one of the best caretakers, he/she just happens to speak loudly. Residents have never expressed discomfort from that. S1 also stated that he/she has never observed staff harm residents or speak to them in an inappropriate manner.

Based on observations, LPA Donato saw residents are comfortable with staff at the facility. Residents are always talking to staff when they need anything.

Regarding the allegation of staff did not provide resident with first aid, RP stated that R1 had an issue with one of his/her knees, and R1 needed ice placed on his/her knee. However, instead of assisting R1, staff stated "things have to be written out."

S1 mentioned that when asked if a doctor's order is needed to apply ice to a resident's wound daily, ADM1 stated that they would. Facility needs to get doctors’ orders.

Regarding the allegation of Staff did not inform appropriate parties regarding resident's change in condition, RP states that R1 was given new medication, and that the resident became withdrawn. However, staff did report the resident's condition to the conservator, nor consult the conservator prior to the resident being prescribed new medication.

According to S1, in the beginning R1 had an incontinence medication that the doctor wanted to stop. R1 was seeing things that weren't really happening, when R1 told the doctor that, the doctor stopped the incontinence medication because they cause confusion. The family came to ADM1 and asked why a medication (M1) was at 50mg instead of 25mg as per usual. The family wanted M1 be reduced to 25mg, which began the start of the confusion phase. The doctor was surprised that the family was not approving the increase in dose of medication. ADM1 stated that they were not sure when the medication dosage was increased and if the family was notified of the change. ADM1 also shared that they only follow what medication the doctor prescribes.