Complaint Investigation Report

R1 shared that they have cancer that has spread to their bones and receive hospice services, and stated they feel staff do not respond to their needs in a timely manner. R1 has resided at the facility since October 2025.

Review of R1’s Physician’s Report dated March 10, 2026 revealed that R1 is ambulatory, able to communicate their needs, able to follow directions, and can feed themself. R1’s primary diagnosis is prostate cancer. The report also notes that R1 is able to self-administer both prescription and PRN (as needed) medications, though the facility began managing their medications following hospice recommendations. Review of R1’s Care Plan dated January 31, 2026 indicated that R1 elected hospice services due to a change in condition. The plan outlines that facility staff are responsible for coordinating care with hospice and notifying hospice staff of any changes. The plan notes that R1 sometimes needs assistance with activities of daily living (ADLs) when feeling weak. A hospice nurse visits the facility 2–3 times per week. The care plan emphasizes promoting R1’s independence while maintaining dignity and safety and encouraging R1 to participate in their own self-care with minimal cues when appropriate.

Review of R1’s Medication Administration Records for March 2026 shows that R1 received their PRN morphine for pain on multiple dates throughout the month, with documentation showing consistent administration when requested and within the allowed time intervals. R1’s PRN Ondansetron was also administered on several dates for nausea and vomiting. The lidocaine 4% patch was noted as “awaiting delivery” from March 1 through March 22. Once the patch became available, R1 refused it consistently from March 22 through March 27, and the medication was discontinued on March 29 per the physician. R1’s only routine (daily) medication, trazodone 50 mg, was administered every day in March except March 28, when R1 was documented as being out in the community. MAR entries show medication administration consistent with physician orders, PRN usage rules, and documented resident refusals.

Review of the RCD progress notes showed a consistent history of behavioral and communication challenges with R1. Notes from January 2, 2026 document that R1 began insulin and was verbally rude to staff and exhibited repetitive calling behavior. On January 14, R1 expressed confusion and repeatedly called for the RCD, expecting nursing-level care which the RCD explained she could not provide. On February 1, staff reported that R1 continued displaying rude behavior and refused staff assistance with room organization or medication oversight. The RCD involved hospice and R1’s outside medical team to discuss care planning.