Complaint Investigation Report

Staff changed the resident's service plan without the consent of the resident's authorized person:

The allegation is that resident R1's family member (FM) does not agree with the request from the facility to hire 24x7 1:1 private caregiver for R1.

On 2/22/2024, LPA interviewed previous Executive Director (PED). PED stated he/she communicated with resident R1's family member (FM) and explained to FM the reasons why R1 needs 24x7 1:1 caregiver immediately. PED stated he/she sent a letter to FM to notify FM that R1 needs 24x7 1:1 caregiver.

LPA interviewed a staff S1. S1 stated resident R1 needed 1:1 caregiver due to his/her aggressive behavior.

LPA interviewed a staff S2. S2 stated resident R1 needed 1:1 caregiver because he/she continued to have aggressive behavior to others. S2 stated before LPA visit, R1 was just sent to hospital due to aggressive behavior.

On 2/23/2024, LPA received an email from PED which describing the incidents regarding R1. PED stated on 1/242024, R1 was confusion and with aggressive behavior to staff. On 1/25/2024, PED called R1's family member (FM) for requesting 1:1 private caregiver for R1 because R1's aggressive behavior. The reason for 1:1 private caregiver is for the safety for resident R1 and other residents in the facility. The formal letter to request 1:1 private caregiver was emailed to FM on 1/25/2024.

On 1/26/2024, R1 started to have 1:1 caregiver for 10 hours daily because FM did not agree 24 hours x 7 days and wanted to limit to 10 hours daily. PED stated he/she communicated with FM and R1's another family member (FM1) that R1 needs 24x7 1:1 caregiver. PED stated FM and FM1 understood the requirement of 24 hours x 7 days 1:1 caregiver for R1.

On 2/5/2024, The facility staff had a meeting with FM and FM1 to discuss R1's continuos aggressive behavior.