Complaint Investigation Report

The investigation revealed the following: Allegation #1- Facility staff did not provide resident with water resulting in dehydration and hospitalization.

The details of the complaint alleged that the facility did not take the time to regularly feed R1 because R1 was admitted to the hospital on 12/2/2022 and was diagnosed with dehydration and weighed only 83lbs. On 03/22/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R7) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 2 of 5 staff denied the allegation that Facility staff did not provide resident with water resulting in dehydration and hospitalization, while the other three (S3-S5) staff stated that they did not know the resident because the resident was not here when they were hired. S1-S2 stated that the resident was in hospice and had trouble eating and drinking fluids. S1 stated that R1 was on a liquid diet and fed through a syringe, and that they would give R1 ensure (meal supplement) and shakes but R1 would spit it out regularly, even with a syringe.

S1 also stated that R1 was given water but that R1 would spit that out as well. S2 stated, “the resident was on hospice and steadily declining there was a problem with getting enough fluids in because R1 would spit out the food as well as water because R1 could not keep anything down for too long; maybe that is why R1 was dehydrated but it wasn’t that we were not giving R1 food and drink, R1 just had a hard time keeping it down. Additionally, in the physician’s report it states that the resident is under non-therapeutic measures which means we are to make the resident as comfortable as possible in the last stages of her life”. LPA interviewed R1-R7 about the allegation that the Facility staff did not provide resident with water resulting in dehydration and hospitalization. 6 of 7 residents that were interviewed stated that the facility gives them enough food and fluids throughout the day and have not had any issues with dehydration. LPA reviewed the preplacement appraisal, dated 04/26/2022, and it states that R1 has difficulty in swallowing and is on a pureed diet.

Based on interviews and records reviewed there is insufficient evidence to support the allegation that Facility staff did not provide resident with water resulting in dehydration and hospitalization. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated .