Complaint Investigation Report

Relevant party reported that something had happened to resident (R1) prior to May 25, 2025, when R1 was hospitalized and facility staff did not report changes to R1's authorized representative. LPA conducted interviews with seven (7) staff members, including the Memory Care Director (MCD), who all claimed they noticed a decline in R1 a month or two (2) prior to R1's May 25, 2025 hospitalization. R1 was reported to be moving slower, not eating as much, and not participating in their usual activities. R1's decline was reported to be slow and gradual. Interviews with staff attributed these changes to R1’s dementia diagnosis. Observations made by staff were reported to the Med-Techs and the MCD. MCD claimed that R1 was not sick until the day R1 was sent out to the hospital. MCD stated that, at that time, “everyone” was having a cold in the Memory Care Unit (MCU). R1 had two (2) “accidents” of incontinence which is “out of the ordinary” for R1. MCD confirmed that they were made aware by staff of the changes noticed in R1 and that family and doctor were aware of the changes in resident’s eating habits.

On May 25, 2025, R1 was admitted for (but not limited to) the following:

o Acute metabolic encephalopathy (brain dysfunction caused by an underlying condition. The underlying condition can cause a chemical imbalance in the blood. As a result, the brain doesn’t get what it needs to function as expected. Metabolic encephalopathies usually develop acutely or sub acutely and are reversible if the systemic disorder is treated. If left untreated, however, metabolic encephalopathies may result in secondary structural damage to the brain.)

o Severe sepsis (a serious condition in which the body responds improperly to an infection. The infection-fighting processes turn on the body, causing the organs to work poorly. Sepsis may progress to septic shock – a dramatic drop in blood pressure that can damage the lungs, kidneys, liver and other organs. When the damage is severe, it can lead to death) secondary to community-acquired pneumonia

o Mass in the left mid lung (previously noted on R1's previous hospitalization on March 5, 2024).

R1 completed a five (5) day course of antibiotics for pneumonia. After discussions of need for lung mass biopsy and risks of potential chemotherapy, R1's family decided to not pursue biopsy. During R1's admission, R1 was noted to be an aspiration risk, and R1 was made NPO (nothing by mouth). Repeat evaluation allowed upgrade to a dysphagia diet, but R1 remained with poor oral intake due to lack of appetite. Family was not interested in artificial nutrition or feeding tube. After palliative and hospice team discussions, family decided on hospice. R1 was discharged on hospice on May 30, 2025.