Complaint Investigation Report

Staff did not ensure resident was hydrated.

It was alleged that due to severe dehydration R1’s health condition got more complicated. Staff revealed that they keep resident hydrated at all times. Between 06/23/23 and 06/25/23 R1 was having swallowing difficulties but was able to intake fluids. Staff informed hospice services and staff also spoke to R1’s responsible party, who called 911.

A review of hospice records revealed that R1 ate and drank regularly. R1 was assessed for hydration during skilled nursing visits and there were no signs of dehydration. Other witnesses interviewed during investigation revealed that they saw a “two-liter bottle” of water by R1.

Due to finding no evidence to suggest fluids were withheld or any actions or lack thereof by staff contributed to R1s dehydration, there is not sufficient information to support the allegation, Therefore, the above stated allegation is determined to be unsubstantiated at this time.

Staff did not observe a change in resident's condition

It was alleged that Staff did not observe a change in R1s condition. Interviews with staff on 06/30/23, 10/31/2023, and interviews conducted during the course of the investigation reveal that staff noticed R1’s wounds not healing. Staff revealed that as of 06/14/2023, they noticed that R1 was having swallowing difficulties and developed prohibited health conditions, posing immediate danger to R1’s health and safety.

Based on interviews and records review staff monitored R1s condition and noticed changes in R1s condition consequently there is insufficient information to support the allegation. Therefore, the above stated allegation is determined to be unsubstantiated at this time.

Exit interview conducted/Appeals/Copy of report given.