Complaint Investigation Report

To investigate the allegation, the LPA conducted staff interviews, and obtained pertinent documents during both initial and subsequent visits. Staff interviews revealed that there have been occasions when R1’s responsible party has requested resident records and/or incident reports and was denied the records. Administrator Amber admitted that the previous Administrator, Michael O’Neil, would not provide records unless they were subpoenaed. In addition, record review revealed that Health Services Director (HSD) stated “Incidents are written on internal documents, which we do not provide. Internal documents are for the Artesian staff only” to R1’s responsible party via email. Lastly, HSD admitted that they have denied documents to R1’s responsible party due to being instructed to do so by previous administrator and was unaware what documents could be provided to a resident’s responsible party. Based on interviews and record review, there is sufficient evidence to support the allegation that Facility refuses to provide resident records and incident reports to resident’s responsible party. The allegation is deemed Substantiated at this time.

It was alleged that Resident incident reports are not being reported to RP and Licensing. To investigate the allegation, the LPA conducted staff interviews, and obtained pertinent documents during both initial and subsequent visits. Staff interviews revealed that when there are resident incidents, staff will either document the incident as observations or complete an Incident report depending on the level of the incident on the facilities Alis application. If the incident is something that needs to be communicated between staff such as a resident not eating all their dinner, it will be documented as an observation. However, if an incident is major such as a fall, a written report will be documented. Responsible parties should be notified of all resident incidents, and licensing should be notified via an Unusual/Incident Report (LIC624). On 10/10/23, the LPA conducted a file review of all LIC624s reported to the department for the year of 2023 and did not find any LIC624 submitted for R1. However, document review revealed that R1 has had seven (7) separate incidents within 2023. Management gave conflicting answers as to who was responsible to submit LIC624 to licensing. Based on interviews and record review, there is sufficient evidence to support the allegation that Resident incident reports are not being reported to RP and Licensing. The allegation is deemed Substantiated at this time.