Complaint Investigation Report

During LPA investigative visit, as well as previous visits, LPA observed staff preparing resident’s meal according to resident’s specific dietary needs as outlined in their ISP. Additionally, complaint alleges resident’s legs not being elevated per their care plan because their hospital bed was broken. Investigation revealed that bed’s foot raising feature was broken for approximately one week. However, the primary way by which resident’s legs were elevated is by use of wedges and pillows. The bed being broken did not prohibit resident’s legs from being elevated as the foot raising feature was used as a supplemental aid to help raise and elevate the legs; it was not the main source of elevation. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Complaint alleges Personal Rights. RP states that resident postural support chair (recliner) was not implemented timely by facility which resulted in resident not being able to be in common areas of facility. During investigation, LPA reviewed doctor’s orders and there is no mention of a postural support chair being needed. Resident’s wound care doctor noted that the legs being elevated would be good but did not specify the method by which the legs should be elevated. Investigation revealed that request was made by resident’s POA for a postural support chair in beginning in March. Per LPA interviews, POA wanted the recliner placed in a certain area of the home, in order to accommodate the request, facility needed to stabilize the base of the recliner and made the request to do so with a handyman. On April 18, 2024 facility added the use of a recliner to resident’s care plan. On April 30, 2024 LPA received a request inquiry from facility in regards to the use of a recliner for resident as a postural support chair. LPA and facility discussed maintaining compliance with regulations as pertains to implementing the recliner as part of resident’s care plan. On May 7, 2024 LPA gave the okay for use of the recliner. Per LPA investigation facility addressed recliner request and made the required notifications and requests to licensing within a span of 60 days. The absence of the recliner chair cannot confirm that resident that resident was isolated due to lack of chair. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.