Complaint Investigation Report

two (2) hours during the day and every three (3) hours in the early morning. Based on the investigation the above allegations are substantiated.

Resident became severely dehydrated in facility .

Reporting Party (RP) reported Resident became severely dehydrated in facility. Based on record review of facility’s incident report Resident 2 (R2) was transported to the hospital on 12/25/2019 and discharged on 12/29/2019. Discharge summary report from the hospital did not indicate that R2 was dehydrated, but R2 did have an unspecified infection pending lab results.

Staff did not administer resident’s medications per physician’s order .

RP stated that R1 was prescribed medication and the facility stopped administering the medication which sent R1 back to the hospital. Based on record review and interview the medication for resident was discontinued on 5/05/2020. S2 stated during interview that staff faxed R1’s doctor on 5/23/2020 to confirm medication had stopped because R1 had been in and out of the hospital and there were a lot of changes. S2 also stated that R1 was given two (2) prescriptions for same medication and both were stopped.

Staff did not obtain timely medical care for resident

RP reported the doctor had requested R1 to return to the hospital after R1 had called the doctor and the facility resisted to call 9-1-1 until two (2) to three (3) hours later. During record review LPA observed facility's incident report dated 5/10/2020 at 7:30PM, indicated R1 was assessed by staff and staff contacted advice nurse.