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32 | The investigation reveals the following: “Staff does not follow the resident's care plan. “It is alleged that staff have not been following R1’s new care plan since March of this year, which requires the facility to check on R1 4 times a shift. According to the administrator, the staff checks on R1 4 times a shift, but R1 does not like the staff in their rooms, and they are one of their independent residents. Staff check on R1 in the morning while R1 is sleeping, but don’t wake R1 because they don't like it. The administrator further stated that when R1 is out in the facility, staff visually check on them. All interviewed staff denied the allegation, stating that when R1 is around the facility, they visually check on R1. 1 out of 10 residents stated that although they are around the facility, they prefer staff to physically address them for it to count as a check. 9 out of 10 residents denied the allegation, stating that staff provide great care. LPA reviewed R1’s care plan and noted that it stated 4 times per shift, but it did not outline who conducts the checks or how they are to be conducted when the resident is not in their room. LPA also reviewed the document provided by R1, titled "Communication with Administrator." The document contained the dates and initials of night-shift staff who signed off, confirming they conducted checks on R1. When the document was presented to the administrator, they stated that it was not an internal document and that they had not seen it. The administrator stated that the signatures resembled R1’s handwriting and that staff had not informed them of the document. LPA attempted to contact the staff listed on the document and left a message for a return call.
The investigation reveals the following: “Resident sustained several injuries due to staff neglect or physical abuse. “It is alleged that R1 received head trauma, fell, broke their nose, and had to be in the hospital. The administrator denied the allegation, stating that in February, the residents had a fall and bruised their faces, but refused to go to the doctor. The administrator stated that R1 eventually went to their own doctors and refused to provide the facility with discharge paperwork. 1 out of 4 staff members stated that when they checked on R1, they saw a bruise, and R1 refused to go to the doctor. They contacted the medtechs to check on R1. 1 of 4 staff members reported that R1 had a fall in February, resulting in a bruise. They further stated that R1 didn’t call anyone because R1 was drinking, and they believed R1 felt embarrassed. All staff denied neglecting or abusing the residents. 10 out of 10 residents denied that the facility neglected or abused them.
Report continued on 9099c
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