Complaint Investigation Report

Based on records review of C1’s physician report dated 7/5/24, centrally stored medication and destruction record, facility medication administration records (MAR) for the month of August 2024 confirmed that medication Olanzapine 5mg tabs were prescribed as follow: “take 1 tablet by mouth nightly for psychosis. Can take up to half tablet (2.5mg) twice daily as needed for agitation”. The MAR records indicated that C1 was assisted by staff with the medication as prescribed by their physician nights prior to the incident. A finding that the complaint allegation of staff did not ensure resident was provided their medication as prescribed is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Another allegation was received about staff are not adequately trained. The Reporting party raised concerns about staff training due to accompanying staff (name unknown) stated that client (C1) had been escalating for a couple of days into agitation and aggressive behavior, where the police had to be called out three times to the facility, but when staff was inquired regarding the type of intervention that they provide at the facility, staff did not have an answer. Based on records review, LPA reviewed staff training records (S1, S2, S3, S4 & S5) have received hours annual of training required per regulation. Based on LPA’s interviews conducted with staff (S1, S2 & S3) confirmed that they have received training and have described the techniques of de-escalation provided to them during their training including, but not limited to active listening, redirection, relaxation, structure choices, active ignoring, verbal contact, differential reinforcement, screening techniques, voice tone and speed, use of touch to get attention by using gestures and body language for clarification, allowing time for client to respond. The techniques described appears to be adequate for this type of incidents. A finding that the complaint allegation of staff is not adequately trained is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.