Complaint Investigation Report

Wellness communication notes were reviewed and noted on 3/18/22, R1 was found on floor at 0710 and 911 was called. R1 returned the same day and then on 3/19/22, R1 was found on floor at 0500 and again around 1202PM, R1 had an unwitnessed fall. Nothing was noted regarding the use of walker which corroborated with the staff interview on no new instruction was given after the first fall.

The review of MAR of March and April 2022 noted several medications (Miralax, Metformin, Insulin to name a few) were not given to R1 per doctor’s orders (11 days in March and 8 days in April) with no staff initials and no reasonable explanation as to why they were not given or missed.

1 Out of 1 staff interviewed stated MAR would specify the reason why a resident missed the medication.

The Department has investigated the above allegations. Based on records reviews, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty in the amount of $10,000.00 for violation resulting in serious bodily injury is pending review.

Exit interview was conducted with JL. This report and LIC9099-D were provided to JL.