Complaint·September 29, 2023

On 09/19/2023, a second LPA received documented records of the facility call button system usage for each resident from September 2023. The facility Call History documentation lists the call type: Emergency calls, Area, Room, Floor, Call Time, Wait Time, and name of the resident calling. From the documented facility call history, all resident call button usage was responded to by staff members. Wait time for each call varied depending on the type of call, as Emergency calls were responded to immediately. On 09/19/2023, LPA interviewed residents about the allegation and no resident interviewed by the LPA stated that they had been ignored by the staff of the facility when they pressed their call button. There is no evidence of inadequate staffing during the hours recorded on the call button documentation, and there were no long wait times by residents. The facility call button history documentation shows that the wait times for residents in the facility did not increase in length in proportion to the number of calls a resident made on the call button sequentially. The Call Button History Documentation shows that all residents had a wait time from less than a minute to approximately under half an hour. All residents interviewed by the second LPA on 09/19/2023 stated Staff members were very good with bathing procedures and the changing of linens in the residents’ rooms. Staff members interviewed stated that residents are checked up on regularly/periodically and there is no time a resident would be left for 3 hours or more after having pressed the call button for assistance. This is corroborated by the record review documentation of the facility call button system usage. There is no evidence to corroborate/confirm the allegation that the facility staff are not meeting the incontinence needs of the resident(s) in care. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Resident sustained injury while in care. It is alleged that a resident had a wound on their hand that staff re-opened when they grabbed the resident by their hand to help the resident. RP stated that the wound bled from the incident. There is no evidence to corroborate the allegation that a resident sustained injury while in care. On 09/21/2022, the original LPA assigned to the complaint could find no evidence through interviews and record review to confirm that the resident had received the wound while in care at the facility. On 09/19/2023, the second LPA conducted interviews with Staff members and residents of the facility. No interview divulged any evidence that a resident had sustained an injury while in care at the facility. No resident stated they had sustained a wound in care, or ever seen another resident sustain a wound in care. Continued on 9099-C No Staff member stated that they had ever re-opened a wound in care on a resident. Record review by the second LPA did not discover any evidence that a resident sustained a wound while in care. LPA received Physicians Orders/Audits from the primary care physician of certain residents dated from September of 2023 on a consistent basis (every day to every other day/occasionally every 3 days). LPA received copies of Medical Services provided to residents, regarding any wound a resident might have received while in care. LPA also received documentation of medical examinations for residents in September 2023. LPA received a copy of residents’ discharge summary from the hospital in August and September of 2023. LPA received detailed Doctor's Progress Notes from August 2023 and September 2023. LPA also received documentation of the facility 24 Hour Chart Check for the Resident for the months of August and September 2023. Interviews with facility staff members indicated that fragile or thin skin that tears easily is a concern with individuals at a certain age, but no resident had been moved by Facility Staff resulting in a wound opening up on the resident that bled. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff does not communicate with authorized representative. It is alleged that the Staff members of the facility did not let the authorized representative of a resident know about the wound on the resident’s hand that had been re-opened due to the Staff grabbing the hand of the resident. The allegation also states that there is currently no management person that a resident or family member can contact for any reason. The facility does not contact family members in cases of medical or residential emergencies. RP alleges that the facility does not know what medications they are giving to their residents who are under medication management. On 09/21/2022, LPA conducted an initial complaint investigation visit to the facility above. LPA found no evidence that the facility had no management individual that a resident or family member could contact. The Administrator was listed on the LIC 500 Personnel Report, including the hours that the Administrator would be in the facility. At the time of the LPA visit, the Administrator was present in the facility and spoken with. According to interviews with Staff members and residents, the Administrator was in contact with Authorized Representatives on a continuing basis. On 09/19/2023, a separate LPA conducted interview, observation, and record review at the facility above. LPA found no evidence that corroborated the allegation of the facility not contacting family members of residents in cases of medical emergencies. Continued on 9099-C There is documented evidence including interview and record review that the Administrator of the facility does contact relatives/representatives in cases of resident medical emergencies, and the Administrator of the facility is very open about contact with family members. This includes having signs in the facility which detail contact information the family members/representatives can use to communicate with the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff failed to give medications as prescribed. It is alleged by RP that medications were not given to residents due to being out and were not refilled timely. RP requested if staff could let them know if the resident’s medications are current, but staff did not have knowledge of the medication. RP alleges that the facility cannot provide a record, over the course of 5 days of what medications they have provided to certain residents. On 09/21/2022, the first LPA assigned to this complaint conducted an initial complaint investigation visit to the facility above. LPA interviewed staff members and residents in the facility. Neither staff members nor residents confirmed the allegation. Staff interviewed stated they had not observed any resident being given incorrect medications. LPA did not observe any evidence of the allegation while at the facility. On 09/21/2022, LPA received documentation of daily medications given to residents, as well as the Centrally Stored Medication & Destruction Record. On 09/19/2023, a separate LPA conducted record review of the records/documentation of medication for residents and the Centrally Stored Medication and Destruction Record received by separate LPA from the facility on 09/19/2023. No errors or questionable staff marking were found in any of the resident medication documentation. LPA saw no incidents between 09/06/2022 through 09/22/2022 in which wrong medications had been documented being given to any resident. On 09/19/2023, the second LPA interviewed residents who stated that they had never been given any wrong medication at the facility or heard of any other resident receiving any incorrect medication. On 09/21/2022, LPA interviewed staff members and obtained records/documentation of medication for residents and the Centrally Stored Medication and Destruction Record. Medication records for September 2022 are documented appropriately with no inconsistencies or absence of documentation. There is no documented evidence to corroborate the allegation. No witnesses interviewed stated seeing or receiving any incorrect medications. On 09/19/2023, separate LPA reviewed the Centrally Stored Medication and Destruction Record for the assisted living portion of the facility. LPA also obtained copies of resident medication records and physician order reports for residents, maintained in each resident’s record/file. Continued on 9099-C LPA observed that all the correct/proper medications were logged as having been given to each resident, and an audit of the actual medications stored in the assisted living portion of the facility matched the records maintained by the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff are insufficient in numbers/knowledge to meet the residents’ needs. It is alleged that there are no facility staff on in the evenings or weekends that are employed by the facility. There are no caregivers that work for the facility that assist residents from Friday nights through Monday mornings. Outside agencies are trying to provide care but are minimal in their numbers. On 09/21/2022, the first LPA observed the Staff of the facility while at the facility for the initial complaint investigation visit. The LPA observed all staff members answering radio calls and attending to residents on a consistent basis. On 09/19/2023, the second LPA interviewed witnesses who indicated that staff members are attentive to the needs of residents in a timely manner at the facility. LPA did not observe any received radio call by facility staff members go unanswered or ignored. On 09/19/2023, LPA observed staff members answering all calls for assistance in a timely manner and attending to residents when/if needed. LPA did not observe any staff refusing or neglecting residents at the facility. LPA received documentation from the facility regarding employed Staff members including an LIC 500 Personnel Report and Staff schedule. LPA found no evidence to corroborate the allegation that there are not enough Staff members to meet the needs of residents in the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of the report provided to the facility.