complaint·April 7, 2021

A review of the Residency Agreement, which was signed by R1 on 1/17/2020, details the Medication Program Fee. The Medication Program Fee describes that if the resident assessment indicates that a resident is unable to self-manage their medications, then the resident is placed on a Medical Program Level. The full assessment is derived from reviewing the physician’s report, scheduled reviews of the medication regimen, and consultation with the resident’s primary care physician. Documents reviewed, including R2’s physician’s report, noted that R2 could not manage their own medications. In addition, there was no documentation from R1 nor R2’s physician noting that R1 was assigned to assist R2 with their medications. Lastly, a review of this facility’s Plan of Operation indicates that residents will be assisted with the self-administration of medication by a trained staff person. As such, R2 was deemed appropriate for the Medication Management Program and was noted within the Medication Level 1 category. Based on the information, the staff was unable to allow R1 to assist R2 with the self-administration of medication due to policy. This allegation is deemed Unsubstantiated at this time. Allegation: Staff interrupts resident's sleep. It was alleged that staff were conducting room checks every two hours, even at night, and it was noted as invasive. A review of R1 and R2's completed assessments revealed that although R1 did not require two-hour room checks, R2’s Assessment completed 3/10/2020 noted that R2 was on two-hour status checks due to their diagnosis. Interviews revealed that for safety measures, staff conduct two-hour checks throughout the day, even during the nighttime. Staff stated that they are required to go into the resident’s room to assess for safety and to manage care needs (such as addressing any incontinence), yet they try to do so in a non-invasive and quiet manner. Staff stated that in the off chance that they woke someone up, they always apologized. A review of R1 and R2’s Residency Agreement, along with the Comprehensive Assessments, discusses reasons why facility staff would come into the room to conduct resident checks. Interviews revealed that most residents had to adjust to the regular staff checks, as some were previously independent and were not used to staff coming in every two hours to ensure that their needs were being met. Based on the information obtained, there is insufficient evidence to support the claim that staff interrupts resident’s sleep. Whereas it may be an inconvenience for some for staff to come into the room to conduct status checks throughout the night, it is a part of facility protocol to meet care needs and to assess for safety. In addition, an interview with R1 revealed that staff had not woken them up, yet they felt that the overall system of two-hour checks was invasive. R1 claimed that they were about to go to sleep, when staff came in to check in R1 and R2. This allegation is deemed Unsubstantiated at this time. Allegation: Facility staff are not providing resident privacy It was alleged that staff were coming into the room throughout the day for various reasons without obtaining permission from residents. Interviews and documentation reviewed revealed that whereas residents are indeed afforded privacy, the Residency Agreement states that ‘staff will enter the Apartment upon reasonable notice and during reasonable hours to clean, inspect, repair, alter, or conduct maintenance that they may deem necessary for the reasonable care of the Apartment’. In addition, it notes that ‘… whenever feasible, reasonable notice will be provided before a representative enters the Apartment. ’ Resident interviews revealed that it is rare that a facility representative schedules an appointment to provide care or to fix something; yet, upon entry, they will ask permission as to whether they can enter the Apartment to provide the appropriate assistance. Interviews revealed that residents had to adjust to facility representatives coming in to provide assistance, but mentioned they were always polite and asked permission upon entry. Resident interviews further revealed that they did not feel that their was an infringement of their privacy when the staff would come in to provide assistance. Whereas all residents have the ability to lock their door, the House Rules notes that for housekeeping and maintenance requests, select members of staff have a passkey that allows them access to all rooms to complete required updates and requests. Based on the information obtained, there is insufficient evidence to support the claim that facility staff are not providing resident privacy. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. Signatures obtained. A copy of the report was emailed.