Complaint Investigation Report

The facility spoke with hospice about taking care of R1, hospice advised the facility that they would take care of R1 and the facility could assist them when hospice nurses needed or requested help and/or assistance. Hospice nurses were taking care of R#1 24/7, R#1 had continuous care. R#1 always had around the clock nurse taking care of R#1 and facility staff available when needed. The family hired an additional care giver for R1 to assist hospice with R1. Interviews with R#2 & R#3 stated that they did not need repositioning, but the staff there are great. They help them with all their needs. LPA reviewed hospice notes and facility care plan revealed that the repositioning of R#1 was done by the hospice nurses and staff would help at times, when requested and needed and would check in on R1 every 2/3 hours. The interviews conducted and records reviewed did not concur with the above allegation.

Allegation 2 - Staff did not change diapers timely. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice advised the facility staff that R1did not need R1’s diapers changed since R#1 had G-tube, so there was no need to change the diapers. Staff spoke with Silverado hospice and explained the even though R#1 had a G-tube R#1 still required to have the diaper checked and change if needed. Facility staff would go to check R1 to see if R1 needed a diaper change and/or see if Hospice needed their help. Interviews with R#2 stated R#2 does not need diapers, R#2 goes to the bathroom on her own. R#3 stated the staff only changes R#3 diapers at night in morning R#3 goes to the bathroom on her own. They never leave R#3 in a soiled diaper. LPA Soto reviewed hospice notes they revealed that they were changing R#1 diapers every 3 hrs. when and if needed and would check in on R1 every 2/3 hours. R#1 always had around the clock nurse taking care of R#1 and facility staff available when needed. The family hired an additional care giver for R1 to assist hospice with R1. Interviews conducted and records reviewed did not concur with the above allegation.

Allegation 3 - Staff did not bathe resident. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice would take care of bathing R#1. Hospice would give R#1 sponge bath every morning. Facility staff would wash R#1 hair to help hospice nurses. Interviews with R#2, stated that R#2 bathes themselves. R#3 stated that the staff bathes R#3 3x a week, they are very good about that. LPA Soto reviewed hospice notes dated 11/01/21, they revealed that Silverado hospice was bathing R#1 every morning. R#1 always had around the clock nurse taking care of R#1 and facility staff available when needed and would check in on R1 every 2/3 hours. The family hired an additional care giver for R1 to assist hospice with R1. Interviews conducted and records reviewed did not concur with the above allegation.