Complaint Investigation Report

W1 stated they were informed that in order to have R1 further evaluated, they would have to remove R1 from hospice care; therefore, W1 stated they did not take R1 to the hospital or call R1’s neurologist. W1 was unable to provide additional evidence of alleged injuries. Per W1, on August 28, 2021, they visited R1 at the facility and upon removing R1’s left shoe, they observed R1’s ankle was swollen and asked S1 if R1 had fallen but S1 was unable to confirm or deny if R1 had fallen. W1 was unable to provide additional evidence of R1’s swollen ankle. Per W1, they also observed three bruises on R1’s right forearm and stated they were caused by a caregiver, however, W1 was unable to identify the caregiver. During interview, Administrator (AD) denied the allegation and stated R1 was never hurt at the facility and they “only saw one discoloration” that was caused by R1 trying to open the screen door and that had been reported to W1. Per AD, S1 had not been employed by the facility since September 2021, and they no longer had any contact information for them, thus S1 could not be interviewed to verify W1’s statements. LPA also attempted to contact Hospice Agency providing care to R1, however, the Agency is no longer operating.

Regarding the allegation, Staff mismanaged resident's medication, the following was revealed: It is alleged that on August 27, 2021, facility staff received an antibiotic for R1 from the pharmacy but placed the medication away in a cabinet and did not start the dosage when received. During interview, W1 stated that on August 27, 2021, they were contacted by a Hospice Nurse who informed them they were able to obtain a urine sample from R1 and determined R1 had a Urinary Tract Infection (UTI) and the doctor wanted to prescribe antibiotics. W1 stated they agreed and personally called the pharmacy. Per W1, they were informed the medication would be delivered to the facility prior to the end of the day so that R1 could start the treatment. W1 stated that on August 28, 2021, they visited R1 at the facility and asked if R1 had their antibiotic that morning. Per W1, S1 informed them they had never received the medication from the pharmacy the night before. W1 stated they immediately called the pharmacy and asked why the antibiotic had not been delivered. Per W1, they were informed the medication had been delivered and given to an unidentified female staff at the facility. W1 stated they requested the closet where medication was stored be checked and staff retrieved two brown bags, one of which one was folded and stapled closed and contained R1’s antibiotic medication. Per W1, they informed Licensee that S1 had not given R1 their antibiotic medication and had not even opened it after it was delivered the night before. W1 stated they advised Licensee they would be removing R1 from their care and on August 29, 2021, they moved R1 to another facility. During interview, AD stated that due to R1 being moved out of the facility on August 29, 2021, they were unable to recall if the medication had been received or administered.