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32 | The investigation revealed the following:
Allegation: Staff did not provide medication to client in a timely manner.
It is alleged that staff is not providing C1 with medication in a timely manner. LPA conducted medication review for 3 Clients with no issues observed. LPA interviewed 2 clients and each denied the allegation, C2 stated they do not take any medications and C3 stated the staff make sure medication is given at the same time every day. LPA obtained copies of C1’s MAR from September 2023-October 2023, there was no documentation of medication errors or medication being administered late. LPA interviewed 2 staff and both confirm that this was investigated by Regional Center and there was a corrective action plan issued along with a required training on medication to be conducted. LPA spoke with Regional Center QA and it was explained that their findings were unsubstantiated and training was a recommendation. Based on the observations made, documentation reviewed and confirmation from Regional Centers findings this has been changed to an unsubstantiated finding.
Allegation: Staff is not following client’s doctor's order.
It is alleged that medication is not being given to C1 per doctors’ orders which would help decrease C1’s seizures. LPA obtained copies of C1’s Seizure Observation Log from 4/13/23-10/8/23 which averaged 2 seizures a month, log did not indicate higher amount of seizure that would suggest the above allegation to be correct. LPA obtained copies of Daily Ongoing Notes from 10/12/23 – 10/29/23 that documented C1 was taking medication daily. LPA interviewed 2 clients and both denied the allegation and stated they feel the staff follow doctors orders including taking them to the doctors when they are not feeling well and taking them to their routinely scheduled appointments.
Allegation: Staff did not follow client’s dietary needs.
It is alleged that staff are not providing C1 with a proper diet. LPA interviewed 2 clients and each denied the allegation stating that facility maintains their dietary needs and are provided with snack and 3 meals a day which they can get second servings if needed. LPA obtained copies of C1's Fluid Intake Chart from 10/22/23-10/27/23 that documented how much fluids C1 was consuming. LPA reviewed facility food supply and although it was low, there appeared to be the required 7-day nonperishable and 2-day perishable food supply, administrator stated that they are planning to do a grocery run for facility tomorrow 4/7/26 which is the regularly scheduled restock day, to ensure there is enough food supply at all times in the facility.
Based on statements and interviews conducted with staff and clients, review of C1's files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview held, and a copy of this report was provided.
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