Complaint Investigation Report

Discharge documents for R1 confirmed that R1 was discharged the same day with a diagnosis of facial laceration and closed head injury. R1’s care plan dated 6/23/23 indicates that due to their memory challenges, it was determined that staff will escort resident to the bathroom, give verbal prompts/cues with toileting tasks. However, R1’s physician report dated 9/25/23 revealed that R1 is capable for self-care including toileting needs. Although R1 had a fall, the investigation did not reveal information that injury while in care was due to any lack of supervision. A finding that the complaint allegation of resident sustained an injury while in care 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.

Staff do not ensure adequate care and supervision is provided to residents. The Reporting party stated that they noticed residents in the memory care unit with bumps on their heads that weren't there before due to staff do not check on residents as often as they should do, the staff are supposed to be checking on residents every two hours to repositioning or taking them to the bathrooms, but they are just logging into the paperwork that they did, but it is not happening. During LPA’s interviews with reporting party, LPA requested names of staff or residents, but complainant could not provide any further details. Based on records review of facility records, staff are assigned tasks that are documented into the assignment sheet/ADL’s checklist/NOC memory care round checks sheet. Upon reviewing facility logs as follow: assignment sheet for the month of August 2024 indicates at least two staff need to be present in memory care unit to assist residents in care. ADL’s checklist for the month of August 2024 indicates that staff have ensured that each resident’s care plan and needs are being met daily. NOC memory care round check sheet information details continence status as well as how each resident was found including on recliner, sleeping, etc. during checks performed at 10pm, 12 am, 2am, 4am and 6am respectively. Staff schedule and staff timesheet for the month of August 2024 confirmed that there is an average of two caregivers, med-technician/aide per morning and afternoon shift, two caregivers at night shift to provide care and supervision for nine residents in memory care unit.