Complaint Investigation Report

9099C-1.. Allegation: Staff did not seek medical attention for a resident in care. The allegation states on Friday 05/02/2025, resident (R1) was "throwing up" after eating lunch, did not eat any food for two days and was very weak, and the staff did not take (R1) to see a doctor.

Facility documents show that (R1) was placed under hospice care on April 8, 2025 and remained under their care until they passed on 5/30/2025.

(R1) stated to LPA on 5/8/25, "Yes, I was really sick- I called my daughter, who was very concerned". (R1) stated she got sick after she ate soup and then "only had liquids for the next couple of days and asked for water".

One staff stated on 5/8/2025 that she is "not aware" of (R1) getting sick recently, and there have been "no changes" with resident's eating or drinking. A second staff was asked about (R1) getting sick and vomiting and commented, "it was only a phlegm- it was not vomiting- it was only one time, after lunch and before dinner. Hospice is aware". This staff explained that (R1) "likes coffee every morning and ate lunch that day", adding (R1) also likes soup, will eat a small lunch and sometimes also a small dinner. This staff explained "every time (R1) asks for juice or a snack, we give it to (R1)" and snacks are offered two hours after each meal also, and commented "we serve soup often".

A Med-Tech staff stated she recalls (R1) getting sick one time, after lunch, in early May 2025 but is not sure what caused (R1) to get sick. This staff stated (R1) would have "still been offered food and (R1) played with their food" a lot.

A friend of (R1) stated she visited (R1) on 5/2/2025 and observed that (R1) did not feel well and stated (R1) suffered from constipation which can cause vomiting. This individual stated that (R1) was very confused on this day and did not get sick from soup but from fish they ate and was not eating after getting sick. This person also stated that one staff told her they don't have enough staff to help take (R1) to the bathroom, which contributed to the constipation problem.