Allegation: Due to lack of supervision, resident has fallen multiple times resulting in injury

It was alleged that due to lack of supervision, resident has fallen multiple times resulting in an injury. During the course of this investigation LPA conducted interviews and reviewed facility records. Based on staff interviews conducted, it was denied that R1 has fallen multiple times that have resulted in injury. It was stated by staff that R1 has a hard time ambulating themselves due to chronic leg pain. As a result, staff is on stand by to assist with R1 with transferring needs. A review of R1’s needs and services plan states that R1’s transferring needs are a full assist. This indicates that R1 is dependent on staff for all transfers in and out of bed. In addition, a review of R1’s daily notes do not have indication that the resident fell and resulted in any injuries. Subsequently, a review of the facility’s special incident reports were conducted which showed that there were no incident reports regarding this resident. Based on the information gathered, it is unclear if due to lack of supervision, resident has fallen multiple times resulting in injury.

Allegation: Facility staff is not notifying authorized representative of concerns with resident

It was alleged that facility staff is not notifying authorized representative of concerns of resident. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on staff interviews, it was learned that the facility was contacting the responsible party via text messages and phone calls to inform them of issues with R1. It was denied by facility staff was not notifying authorized representative of their concerns regarding the resident. A review of R1’s daily notes were conducted. Based on R1’s daily notes, it was stated that on 07/11/2024, R1 was examined by the facility doctor who advised that the resident needed physical and occupational therapy however when the facility contacted the responsible party to start services both services were denied. Consistent notices to the responsible party were provided regarding changes in the regarding R1 were noted in the facilities daily notes and via text messages. Based on the information gathered, it was unclear if the facility staff was not notifying authorized representative of concerns with the resident.

It was alleged that facility staff did not notice residents change in condition. During the course of this investigation, LPA conducted interviews and reviewed facility documentation. Based on interviews with staff it was learned that the facility staff are directed to conduct daily notes of all residents to ensure that all staff are updated on what is going on with the resident. Facility staff state that daily notes are inputted during every shift regarding any updates, changes or observations with each resident. Facility staff deny that they do not communicate these changes with management. A review of R1’s daily notes were conducted. On 06/29/2024 an entry stated that R1 was observed to be disoriented and required more guidance than usual, the resident was not at their baseline. Staff was notified by the resident’s responsible party noticed that R1 was making odd comments and did not understand why these comments were being said. The facility nurse stated they have contacted the facility doctor who then ordered tests to rule out any infections. Based on the information gathered, it is unclear if the facility staff did not notice residents change in condition.

Allegation: Facility staff are not answering residents calls for assistance timely

It was alleged that the facility staff are not answering resident calls for assistance timely. During the course of this investigation, LPA conducted staff and resident interviews and reviewed facility documentation. An interview with 5 staff members were conducted. 5 out 5 staff members deny not answering resident call lights in a timely manner. 5 out 5 staff members state that the staff do a good job helping each other out and will assist a resident within 5-10 minutes. An interview with 7 residents were conducted. 6 out of 7 residents report no issues with getting assistance in a reasonable time period when using their call lights. 1 out 7 residents were unable to answer the question due to medical reasons. A review of the facilities call button log from June 2024-August 2024 show an average time of 5 minutes and 2 seconds. Based on the information gathered, it is unclear if the facility staff are not answering residents calls for assistance timely.

It was alleged that the facility did not seek medication attention in a timely manner. During the course of this investigation, LPA conducted staff interviews and reviewed facility records. Based in interviews conducted, it was denied that the facility does not seek medication attention in a timely manner for any resident. Facility staff report that any changes are documented in the residents’ daily notes as well as any immediate needs the facility staff understands that they should call emergency services. A review of the facilities records were conducted, there are no indication or documentation to show that the facility did not seek medication attention in a timely manner. Based on the information gathered, it is unclear if the facility did not seek medication attention in a timely manner.

Allegation: Facility did not provide safe environment

It was alleged that the facility staff are not answering resident calls for assistance timely. During the course of this investigation, LPA conducted staff and resident interviews and reviewed facility documentation. An interview with 5 staff members were conducted. 5 out 5 staff members deny not providing a safe environment for the residents. An interview with 7 residents were conducted. 6 out of 7 residents report that they feel safe at the facility and report no issues regarding their safety. 1 out 7 residents were unable to answer the question due to medical reasons. Based on the information gathered, it is unclear if the facility staff are not answering residents calls for assistance timely.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.