Complaint Investigation Report

Allegation: Staff member yelled at hospice worker in the presence of residents in care.

Record review of Hospice Record Incident Report (10/01/25 14:03) revealed Staff #1 became verbally aggressive (yelling) and physically came (within 2 feet) towards hospice worker to the point where another caregiver had to pull S1 away from the hospice worker. Hospice worker reported the incident occurred in front of other residents in the home. Record review of video recording revealed S1 and Hospice Staff having a disagreement over a resident’s medication and pain level. S1 also indicated that S1 can prevent the Hospice Staff from returning to the facility. From the beginning to the end of the discussion, S1 and the hospice staff maintained a personal conversational distance. The discussion occurred in front of the common bathroom and R1’s room (45 seconds) and in the entryway hallways (60 seconds). Two alert residents were in the living room for about one minute during the disagreement. The living room is about eleven feet from the common bathroom and about sixteen feet from the entryway. S1 indicated that S1’s voice is naturally loud and the hospice staff walked off while S1 was still talking. Staff #2 indicated that S1 and the Hospice Staff had an argument because of the pill box. The Administrator indicated that S1 started to question the Hospice Staff and Staff snapped back at S1. S1 wasn't screaming at the Hospice Staff. R1’s Responsible Party/Witness 1 indicated R1 was treated great at the facility. Two out of two responsible parties/witnesses (W2 – W3) indicated staff is professional and wonderful.

Regarding the allegation, “Staff member yelled at hospice worker in the presence of residents in care,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

Allegation: Staff do not ensure that resident is administered their medication as prescribed by their physician.

Regarding the allegation, “Staff do not ensure that resident is administered their medication as prescribed by their physician,” it is being alleged that three days of Norco medication was still in stock on 09/22/25. Review of Medication Administration Record (September) revealed Norco was refused on 09/13/25 – 09/14/25 (AM, Noon, and PM) and 09/29/25 – 09/30/25 (PM). Review of Hospice Record Visit Note Addendum (signed 10/09/25) revealed R1 had three days’ worth of medication. Continue to LIC9099-C.