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32 | The investigation revealed the following:
Allegation: Staff is administering a felony drug to resident in care.
It is alleged that C1 tested positive for fentanyl and due to their cognitive disability there is question as to how C1 was able to get a hold of such drug. Investigator L.Garcia investigated the above allegation. Investigator interviewed 4 staff whom denied the allegation and confirmed that C1 did not have any visitors or
outings leading up to the incident. Medical documents were reviewed and it was revealed during the investigation that C1 was prescribed medications which can lead to a positive test result for fentanyl when tested for narcotics. Therefore, based on the above information, there is insufficient evidence to support the allegation and the allegation is deemed “unsubstantiated”.
Allegation: Staff did not provide adequate supervision resulting in resident sustaining an injury.
It is alleged that C1 suffered a fall which resulted in C1 suffering a brain bleed. Investigator L.Garcia investigated the above allegation. C1's IPP was reviewed and it was revealed that C1 has a history of self-injurious behaviors which include suddenly dropping to the floor without anticipation causing frequent head injuries and banging their head to walls. Investigator interviewed 4 staff and staff reported that nothing unusual was noted and no falls were observed at the time of the incident. The medical records revealed that C1 was diagnosed with a Non-traumatic subdural hemorrhage. However, it was undetermined how, when, or where an injury occurred, since there were no witnesses to the behavior or actions that caused the diagnosis. Therefore, based on the above information, there is insufficient evidence to support the allegation and allegation was deemed “unsubstantiated” .
Allegation: Staff did not report incident to CCL.
It is alleged that facility did not report the incident of C1 testing positive for fentanyl while in the hospital nor the incident of C1 suffering a fall that led to a brain bleed that was determined while at hospital. LPA reviewed SIR's that were submitted to the department on or around the alleged incident date of 10/22/2024 and observed an SIR that was received on 10/23/24 stating the C1 was hospitalized on 10/22/24 due to staff noticing a difference in C1's condition. Administrator confirmed that a call was received to facility and with a mention that there was positive fentanyl reading and head injury that C1 sustained, however, there was no circumstantial evidence to prove the validity of the information provided or that the person on the phone was hospital staff, additionally, there was no paperwork provided to facility from the hospital stating the above information. C1 was no longer in the care of the facility as of 10/23/24 as family took over care of client and client never returned to facility, therefore, there were no updated incident reports provided with the additional information as no information was provided. (Continued on LIC9099-C) |