Complaint Investigation Report

The investigation revealed the following:

Regarding allegation: "Staff not assisting resident with medications." It is alleged that the last time the resident received his medication was two days prior to being admitted at the hospital. And the resident alleged that the staff does not check on the resident enough and that he has been in pain for eight days and constipated for three. Based on documents reviewed, R1 was admitted at Huntington Hospital on 9/23/2020 complaining of severe abdominal pain and was diagnosed of pneumonia and renal failure. R1 was assessed by EMS and observed rigidity, pain, distension and tenderness in all four quadrants. On 9/20/2020, R1 complained to staff of having pain related to his catheter and the staff gave R1 medication. Staff indicated that they emptied R1's urine bag but did not document how much nor how the urine looked. LPA reviewed R1's Medication Administration Record (MAR) for Sep. 2020 which indicated that no pain medication was given to R1 except on the evening of 9/20/2020 for moderate to severe pain and in the afternoon on 9/21/2020. On 9/22/2020, the staff indicated that R1's stool was normal and R1 appeared lethargic but noted to have irregular heart rate. However, there was no evidence that the staff re-checked R1 if the pain medication was effective and no evidence that the foley catheter and urine was checked. Reviews of the documents revealed that the facility did not properly monitor the resident who started to deteriorate on 9/20/2020 and did not provide the available medications to R1 to help alleviate his fever on 9/22/2020 and R1's pain. Additionally, based on the records reviewed, the facility did not properly care for R1's foley catheter as there was no documentation that the instruction for catheter irrigation was followed by staff. The facility did not properly care for R1 when the last foley catheter placement was 10 days prior to being admitted to the hospital. Documents showed that this was not performed by the hospice skilled nurse as the last foley catheter change/insertion by hospice was 8/25/2020. Inte rview with a staff indicated that a NOC shift caregiver pulled out the catheter and pushed it back in while providing care. Other staff interviewed indicated that they were also aware of it. Therefore, there was enough supportive evidence to corroborate the allegation.

Based on LPA’s interviews, and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the Assistant Administrator Alexander Solorio along with the Appeals Rights.