Complaint Investigation Report

On the allegation: Insufficient staffing. LPA’s interviewed staff which revealed one staff stated the facility was very short-staffed during April of 2021. One staff stated they were left alone with out help on a shift and had a resident refusing medication with out-of-control behaviors staff had to call family and paramedics they turned in their two weeks’ notice after that incident. One staff stated one night a resident fell and staff had to leave one building with no staff to go over to help another staff in the other building so the residents were left alone. One staff stated there is one Medication Technician on NOC shift for 3 buildings and only 1 staff in each building. One staff stated often there is not enough staffing. A resident interview stated at times they do not get showered sometimes for 4-5 days even when they have asked to be showered, the NOC shift only has one staff, and they were not answering the pendant press and the resident went out the door and could not find anyone on shift. LPA De Leon reviewed the facility records for staff schedules during the month of April 2021. The facility schedule is for two buildings the Maricopa and the Topa Topa buildings are staffed with 1 AM Lead staff is scheduled, and 3 Guides staff are scheduled, on the PM 1 Lead is scheduled and 3 guides are scheduled, the NOC shift has 1 lead and 1 Guide is scheduled, the lead guides scheduled are the lead for both buildings and the guides are in each building. On 80 occasions during the April 1, 2021, to May 1, 2021, schedule, shifts were open, staff called out, staff wasn’t scheduled, AM, PM, and NOC staffed either worked later, came in earlier, or covered additional shifts, and LVN covered some shifts. On the NOC shift schedule for 04/11/2021 and 04/12/2021 1 staff was scheduled as lead for 2 buildings and only 1 staff was scheduled in the Topa Topa building, no guide was scheduled in the Maricopa building so the lead would not have been able to leave the Maricopa building on those nights to help the guide in the Topa Topa building without leaving the Maricopa building without staff. Several staff stated notes were put into the system by the NOC shift around the date of 04/12/2023 shift that in the early am resident (R1) fell or rolled out of bed and staff were instructed to put him back in bed and LVN would check on resident. On those dated the facility was short staffed based on the schedules. Based on the evidence this allegation is deemed Substantiated at this time.