Complaint Investigation Report

Interviews with staff members S1, S2, S3, S4, S5 and Administrators indicated that the facility ensures that the residents are hydrated, including R1. S1, S2, S3, S4, and S5 stated that they give R1 fluids throughout the day. Interviews with staff indicated that they have never witnessed any residents at the facility to be dehydrated.

LPA observed fluid intake for R1 to be documented at the facility from July 19, 2025 to August 10, 2025 and observed fluids to be offered to R1 throughout the day. LPA reviewed text message correspondence from Administrators sent to R1's authorized representative dated July 7, 2025 indicating that R1 was transferred to emergency services "as a precautionary measure" to ensure that R1 did not become dehydrated. LPA observed medical records for R1 regarding medical visits on July 3, 2025, July 7, 2025, and August 2, 2025. LPA also observed Physician Visit Documentation for R1's medical visits conducted on July 15, 2025 and July 25, 2025. LPA did not observe any indication that R1 was dehydrated during medical visits.

Allegation: Facility staff are not following physician's orders

Relevant party reported concerns that facility was not ensuring to follow physician's orders regarding R1's wounds sustained from their day program on July 3, 2025.

Interview with Administrators indicated that the facility was following physician's orders regarding medications provided to R1 regarding the wounds sustained from their day program. Interviews with staff members S1, S2, S3, and S4 indicated that nurses at the facility are responsible for providing medications to the residents in care. Interview with S5 indicated that they followed doctor's orders regarding the medications prescribed to R1 to address wounds sustained from their day program. S5 indicated that they ensured that R1's wounds were cleaned and dressed appropriately. S5 indicated that R1's wounds healed well, which was observed during follow-up medical visits. LPA observed medical records for R1 regarding medical visits on July 3, 2025, July 7, 2025, and August 2, 2025. LPA observed R1 to be prescribed silver sulfadiazine to address wounds during July 3, 2025 visit. Medical records for visit conducted on July 7, 2025 indicates the following: "Presentation is overall reassuring. I do not see any signs of acute infection. I do see extensive epidermal sloughing. The dermis appears to be intact. No cellulitis. No purulent drainage. Patient is in no acute distress."