Daily Check-in Log Analysis
Albemarle County Adult Protective Services, under the authority granted by the Commonwealth of Virginia, obtained copies of the log books used for the Daily Check-in Program from Commonwealth Senior Living. They covered the 252 days from April 10, 2015 through December 26, 2015. The Franklin family later obtained the documents though a Freedom of Information Act request.
The Program Logs (copies of which appear at the bottom of this page) were reviewed and highlighted for analysis as follows:
- Pink highlight means no time was documented for a resident check-in.
- Green highlight means the time documented was later than 11:00 am (per policy, resident check in should be completed by 10:30 am and receptionist testimony stated 30 minutes was adequate time to follow up).
- Yellow highlight means wrong documentation. The Commonwealth Senior Living receptionist documented that Diane had checked-in on Thursday, December 10, 2015, one of the four days during which she lay incapacitated in her bed.
- Orange highlight indicates contradictions among the various versions of the document provided by Commonwealth Senior Living.
- Some of the log content is illegible. In those instances, Commonwealth Senior Living was given the benefit of the doubt and the entry was considered to be correct documentation.
- Many log entries consist of a single number such as “5” or “6” and contain no indication of AM or PM. In those instances where Commonwealth Senior Living had documented the resident as an early riser the entry was considered to be an AM check and it was deemed within the policy guidelines. Otherwise, it was treated as a failure to meet the policy.
Commonwealth Senior Living provided several different versions of the logs for the weeks of December 6, 2015, December 13, 2015 and December 20, 2015. The inconsistencies among the logs made it impossible to determine which, if any, was accurate.
Results of Log Analysis
The records were astonishing — many of the cells were empty and it appeared that residents were routinely unaccounted for in this Program. Check-in times were often documented in the afternoon, several hours after the 10:30 a.m. deadline defined in the Daily Check-in program. The contents of the logs immediately revealed that Commonwealth Senior Living had routinely failed to perform the Daily Check-in program that it promised to its residents.
Commonwealth Senior Living documented that it had successfully checked on all participants in the Daily Check-in program by 11:00 a.m., on only 29 days of the 252 days that were reviewed. On each of these days, as few as two and no more than five residents participated in the Daily Check-in program.
Commonwealth Senior Living failed to complete the Daily Check-in program by 11:00 a.m. on 223 of the 252 days that were reviewed, a staggering failure rate of 88.4%.
Not a single resident that participated in the Daily Check-in program was checked on every day by Commonwealth Senior Living.
The inconsistent, incomplete and incorrect completion of the Daily Check-in process created a high probability that it would fail when a resident needed the protection it was intended to afford.