Complaint Investigation Report

Regarding allegation “Facility does not have adequate emergency plans to meet the needs of all residents” the Reporting Party (RP) expressed concern that Memory Care (MC) residents are locked in their rooms unable to exit in the event of an emergency. Interviews conducted with staff revealed that residents are able to exit their rooms freely, as the doors are not locked from the inside. Facility representatives explained that in the MC unit, resident doors are equipped with storeroom locks which can lock from the outside but remain unlocked from the inside at all times. This measure was implemented due to incidents involving wandering residents attempting to enter other residents’ rooms, as well as residents forgetting which room belongs to them and attempting to open multiple doors. LPA observed a few residents wandering within the MC unit who attempted to open various doors. Also, LPA inspected eight (8) random resident rooms and confirmed that all locks lock from the outside but remain unlocked from the inside at all times. With regard to the allegation that the facility lacks an adequate emergency plan, facility representatives stated that all staff receive training and are assigned responsibilities and specific roles to ensure the safe evacuation and accounting of all residents during an emergency. The facility conducts emergency disaster drills and maintains an up-to-date Emergency Disaster Plan. LPA reviewed the most recent drill documentation and the updated Emergency Disaster Plan and found the facility to be in compliance with applicable regulations. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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 above allegation “Facility does not have adequate emergency plans to meet the needs of all residents” is deemed UNSUBSTANTIATED at this time.

No deficiency related to the allegations were cited. Exit interview conducted. A copy of the report was reviewed and provided.