Allegation #1: Facility staff did not receive on the job training.

The details of the complaint alleged a staff member did not receive on-the-job training. The complainant reported that management allowed them to work on duty without the proper training. The new staff worked on 12/26/23 and was not trained. The complainant did not offer further information on this matter.

On 01/04/24 and 03/07/24, between 10:30 am – 12:00 pm, the Department interviewed the Executive Director (ED1) disputed this allegation. (ED1) stated there were only three (3) new hires during December 2023, and they received in-service training and were adequately trained before they were out on the floor alone. Newly hired staff were hired on 12/01/23, 12/07/23, and 12/15/23. (ED#1) explained it is a combination of online in-service training and practical method training that focuses on a hands-on approach with season staff. Trainings are completed online, and verification of training is provided for the employer a transcript of completed courses.

On 03/07/24 between 01:00 pm – 2:30 pm, the Department interviewed (3) out of (3) staff #1-#3 (S1-S3) who reported they did not observe any newly hired staff who were not trained on their duties. (S1-S3) verified that all staff must complete mandatory online training and hands-on training with seasoned staff before being self assigned to residents.

On 03/07/24 between 02:33 pm – 3:13 pm, the Department interviewed (4) out of (4) residents #1-#4 (R1-R4) were complimentary of staff and felt staff were trained in assisting residents with their daily activities. (R1-R4) declared staff are knowledgeable of their job duties.

(Evaluation Report continues LIC 9099-C)

A review of the three (3) new hire staff training records revealed the staff completed mandatory in-service and practical method training.

Based on the gathered information, there is no sufficient evidence to corroborate the allegation above.

Allegation #2: Facility staff did not ensure resident(s) received medication according to physician’s orders.

It is alleged that the facility failed to adhere to the physician’s order for resident #1 (R1) who did not receive medication as prescribed. The complainant reported (R1) who is on hospice care should have received the narcotic “morphine” on 12/25/23. The complainant reported that no qualified facility staff or hospice staff was available. The complainant claimed that the Executive Director was made aware of the issue and did not respond to the need. The complainant was unable to provide further information on this matter.

On 01/04/24 and 03/07/24, between 10:30 am – 12:00 pm, the Department interviewed the Executive Director (ED1) who denied this allegation. (ED1) claimed this allegation is false. (ED1) stated who worked on 12/25/23 was not made aware that (R1) had issues with the administration of medications. (R1) is on hospice care, and on that day (R1) received all ten (10) prescribed medications as well as Morphine Sulfate (Concentrate) concentrated at 20 Mg/ML.

On 03/07/24 between 01:00 pm – 2:30 pm, the Department interviewed (3) out of (3) staff #1-#3 (S1-S3) who were on duty on 12/25/23, claimed there were no issues with the administration of medications for (R1). (S1-S3) indicated that no residents missed their prescribed medications.

On 03/07/24 between 3:30 pm – 4:47 pm, the Department interviewed (3) out of (3) family representatives witness #1-#3 (W1-W3) claimed to have no problems or concerns with the administration of the medication to residents in care. (W1) power of attorney to (R1) who claimed to be present on daily visits when (R1) is administered the narcotic “Morphine."

(Evaluation Report continues LIC 9099-C)

A review of (R1’s) Medication Administration Record (dated: 12/01/23 -12/31/23) and Controlled Drug Record Chart (dated: 12/19/23 – 01/20/24) revealed to be complete and accurate. According to the facility's visitor's log, (W1) and Roze Room Hospice visited on 12/25/23.

Based on the gathered information, there is no sufficient evidence to support the allegation above.

Allegation #3: Facility staff did not ensure medications were properly stored.

It is alleged the facility staff did not ensure medications were stored properly. The complainant reported on 12/23/23 that a med-tech left work and never returned causing residents with missed medications. The complainant claimed to have observed the medications were left out on trays and were not stored properly in lock-in storage. The complainant did not have further information on this matter.

On 01/04/24 and 03/07/24, between 10:30 am – 12:00 pm the Department interviewed the Executive Director (ED1) claimed this allegation was untrue. (ED1) informed to have been working on 12/23/23 and there were no issues with medications not being stored properly. (ED1) claimed the facility was not short on staff as there were three (3) med-techs on schedule along with (1) (LVN) on 12/23/23. (ED1) confirmed no med-techs ever left and did not return after lunch. (ED1) communicated that it would be problematic for staff to leave medications unattended as there are two staff involved in administering medications. The facility has a policy of double-checking medication administration involves two staff verifying the same information, while single-checking involves a single individual verifying the information.

On 03/07/24 between 01:00 pm – 2:30 pm, the Department interviewed (3) out of (3) staff #1-#3 (S1-S3) who were all on duty on 12/23/23, claimed there was not to be a shortage of staff and unaware of any staff leaving early and not returning. (S1-S3) does not recall observing any medications left out in the open and not stored properly.

(Evaluation Report continues LIC 9099-C)

On 03/07/24 between 3:30 pm – 4:47 pm, the Department interviewed (3) out of (3) family representatives witness #1-#3 (W1-W3) who claimed to have observed problems with medications handled improperly by staff.

During the investigation visits on 01/04/24 and 03/07/24, the Department observed the medication carts stored in locked medication rooms only accessible with an electronic keypad must enter an access code. The medication carts are four drawer steel cabinets equipped with self-locking drawers and a digital keypad, making it impossible for residents to access them. Self-locking drawers will close and lock themselves after a minute if left open. During the Department's observations on 01/04/24 and 03/07/24, two facility staff administered medication to residents.

Based on the gathered information, there is no sufficient evidence to corroborate the allegation above.

Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegations mentioned in this complaint. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

No deficiencies were cited.

This report is mailed to R.A.C. Brittany, LTD Brittany Health Care Ltd .

This report serves as an amendment to clarify finding. It does not supersedes the complaint investigation findings reflected on report created on 05/03/24.