Complaint Investigation Report

Allegation: Resident was severely dehydrated due to neglect- Unsubstantiated

Facility staff, including two (2) Licensed Vocation Nurses (LVN’s) who cared for Resident #1 (R1) all stated R1 was provided juice, milk and water with each meal. In addition, R1’s family provided them with a small refrigerator in their room that was stocked with water. There are also beverages offered in the dining room, bar and Bistro area all day and R1 was ambulatory and had access to these areas. Staff indicated that R1 could express their needs and would ask staff when they needed something. None of the staff ever observed any signs or symptoms of R1 being dehydrated.

Medical Records for R1’s visit on 03/11/2023 states they were treated with IV fluids due to signs of clinical dehydration. However, it does not provide any other information. R1 had a second visit on 03/12/2023 and there was no documentation of dehydration.

Allegation: Resident was severely malnutrition due to neglect- Unsubstantiated

Facility staff, including two LVN’s who cared for R1 all stated R1 ate well. However, R1 would occasionally say they were full and not finish their meal because they did not like what was being served. None of the staff who cared for R1 observed any signs of R1 being malnourished. In addition, R1 was able to communicate their needs and ask staff for what they need.

In February of 2023, staff voice concerns of R1 losing weight which was brought to the attention of R1s physician who prescribed R1 medication to enhance their appetite.

R1 was sent back to the hospital on 03/12/2023, due to low blood pressure reading again. R1 was diagnosed with severe protein calorie malnutrition. However, there is a notation that states this condition was first noted on 03/18/2023, six days after R1’s admission to the hospital, and it is unknown if condition was present at admission on 03/12/2023.