Complaint Investigation Report

The Department’s investigation established that R1 moved into the facility in September 2019, while also under the parallel care of a hospice agency (which means comfort-focused care reserved for persons near end of life). According to their updated LIC624 Physician’s Report dated August 2019, R1 weighed 89.5 pounds (down from 103 pounds just six months prior), was “bedridden,” and was diagnosed with end-stage Alzheimer’s Disease. According to hospice records: by October 2019, R1 slept more during the day, lost another 6.5 pounds over 3 months, and required the assistance of two caregivers (instead of one) to transfer to a wheelchair. By December 2019, R1 slept 18 to 20 hours per day, and spoke an average of six words per day. From December 2019 to February 2020, R1 lost another 8 pounds and now needed to be manually fed all food and drink.

Regarding the allegation that facility staff did not help R1 drink water, CCLD encountered evidence to the contrary: In December 2019, facility staff conducted a reappraisal of R1’s care needs, citing R1’s “cognitive loss,” inability to communicate verbally, dependance on “full assistance” with eating, and staff needing to “assist [in the] dining room for meals.” This reappraisal generated an updated written plan of care, which explicitly stated R1 required “full feeding assistance.” Multiple interviews corroborated that staff routinely helped R1 transfer to a wheelchair, took them to the dining room for meals, and sat one-on-one with R1 while they ate/drank, physically assisting them in doing it and observing how much was consumed. One staff described pro-actively offering “snacks and water” in between meals to memory-impaired residents, specifically because of their communication challenges.

Regarding the allegation that facility staff did not assist R1 with continence care, CCLD encountered evidence to the contrary: R1’s care assessment described them having “cognitive loss” and requiring help with continence care. R1’s written plan of care stated R1 was incontinent of both bowel and bladder, wore disposable briefs, and required “total assistance” with bathroom needs. Multiple staff interviews corroborated that R1 regularly received such help. According to independent hospice records, in October 2019, R1 was identified as having developed a Stage 2 pressure injury on their bottom. However, on February 25, 2020, a hospice nurse documented R1’s pressure injury had “healed.”