complaint·September 17, 2024

The allegation of ‘Staff do not provide adequate care and supervision to a resident’ alleges Resident #1 (R1) was observed to be wandering outside the facility without the presence of staff. The Reporting Party also provided video evidence of R1 outside of the facility without staff present which allegedly occurred on 09/03/2024. Record review revealed that R1 was admitted to the facility in August 2023. R1’s physician’s report indicates R1 cannot leave the facility unassisted due to a diagnosis of dementia. Interviews with residents and staff revealed that R1 has, in the past, left the facility without the assistance of a caregiver. Previously on 07/09/2024, the Department received a complaint, (CONTROL NUMBER 29-AS-20240709121224) alleging staff do not provide adequate care and supervision to R1, as R1 was observed to be wandering outside of the facility unassisted. The allegation was substantiated on 07/11/2024. The Administrator’s plan of correction for the deficiency was to install auditory alarms on facility exits, schedule walks for R1 with the supervision of a caregiver, swap R1’s coffee to decaf, and Increase R1’s inhouse activities. During today’s inspection, the LPA showed the Administrator the video of R1 allegedly being outside of the facility without supervision on 09/03/2024. The Administrator confirmed the person in the video was R1 but stated they were unaware R1 was outside of the facility without staff supervision. During the inspection, the LPA did observe the presence of two caregivers, of which one caregiver being assigned as R1’s 1:1 caregiver. During the interview with Staff #1 (S1) they confirmed they are R1’s 1:1 caregiver although they stated they have been working as R1’s 1:1 caregiver for “One month, couple of months.” R1 stated that S1 had been their caregiver since “last week, maybe the week before.” Based on the interviews conducted, evidence submitted, and file review, there is sufficient evidence to support to the allegation that staff do not provide adequate care and supervision to a resident. Therefore, the allegation of staff do not provide adequate care and supervision to a resident is deemed Substantiated at this time. LPA informed the Administrator that they had been cited on 07/11/2024 at a previous complaint visit (CONTROL NUMBER 29-AS-20240709121224) for failing to follow the same regulation. As this is a repeat violation of the same section of Title 22 Regulations [HSC 1569.312(a)] within last 12 months a civil penalty of $250 is being assessed. LPA informed administrator that failure to correct the deficiency may lead to additional civil penalties. Exit interview was conducted, Appeals Rights discussed, and a copy of the report was provided.