CCLD studied the signal data for five (5) randomly selected, twenty-four-hour days, chosen from the complaint allegation period. During the surveyed days, there were a total of 186 resident pendant calls, of which were answered by staff in ten (10) minutes or less, and a few were answered by staff in fifteen (25) minutes or less. Work schedules showed that on the surveyed days, Licensee consistently utilized third-party staffing agencies, when needed, to plug/fill staffing vacancies which were not already filled internally by facility caregivers.

The interview with the Executive Director explained that a pendant is given to the resident, and interviews with staff, resident family members, and an outside source do not corroborate the allegation.

Staff members' interviews reveal that they use a radio system to communicate and cooperate to respond within a few minutes of each resident's request for help using their call button.

Documentation further showed that facility managers met several times per week to review and discuss signal report data from a quality assurance standpoint.

LPA observations on several occasions confirm that call button requests are responded to promptly.

Interviews of Medication Technicians and Caregivers showed a pattern of teamwork, communication, and clarity of expectation, as it related to responding to resident signal alerts.

This agency has investigated the complaint alleging that the licensee failed to protect the resident from harm and the licensee failed to facilitate medical care for the resident. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report and licensee rights (LIC 9058 03/22) was provided. Associate Executive Director Aileen Spence's signature on this form confirms receipt of these rights.