Complaint Investigation Report

Staff do not attend to resident in care in a timely manner

On 11/06/2023, it was alleged that the facility staff do not attend to resident (R1) in a timely manner when R1 calls out for help and that no one comes to R1 “for a very long time”. The concern was that staff are unable to hear R1 crying for help as R1’s room was located in the back corner.

During the course of this investigation, 10 staff members were interviewed. Based on interview, 10 out of 10 staff state that staff attend to R1 when R1 they hear R1 calling for assistance. It was stated that if staff are busy assisting other residents, then it’s difficult for staff to get to R1 right away. It was stated that the facility frequently checks in with the residents, but they do not have a specific timeframe for how frequently staff are required to check in with the residents. 9 out of 10 staff stated they check in with the residents every 1-2 hours. 1 out of 10 staff stated they conduct “frequent checks” but was unable to elaborate more on the timeframe. It was stated that residents who require more care needs are checked on more often.

Based on staff interviews, it was stated that due to R1’s needs, the facility recommended a 1:1 caregiver for R1 during the night however due to financial reasons, R1 was unable to be provided a 1:1 caregiver. Due to R1’s behaviors during the night, the facility temporarily implemented a NOC shift staff to sit with R1 during the night. It was stated that the staff tried to their best to accommodate to R1’s needs. It was stated that due R1’s behaviors during the night, the facility provided R1 a pendant on 11/08/2024.

Staff did not report resident’s incident to resident’s representative

On 11/06/2023, It was alleged that the facility staff did not report a resident’s fall incident on the night of 10/21/2023 to the R1’s representative/responsible party. The fall incident was verbally reported by R1 to R1’s responsible party and a home health agency nurse. It was reported to R1’s responsible party that R1 fell while being assisted by staff to bed on 10/21/2024. R1’s responsible party informed the facility staff regarding the fall.