Complaint Investigation Report

urinating. This was reported to hospice nurses. On 01/09/2024, R1 complained of bleeding from their genitals. Additionally, staff observed R1 to have slurred speech, vomiting and diarrhea. Interviews and records show that facility staff notified R1’s family, hospice agency and the licensee. An outside agency responded to the facility and began administering R1 comfort care. Subsequent records indicate R1 was weak, unable to thrive and had no appetite. Record reviews and interviews revealed that R1 passed away while receiving hospice services on 01/19/2024.

A sample of residents were interviewed. Interviewed residents were cognizant, organized, and able to communicate with LPA. Residents advised LPA that they are satisfied with the responsiveness of staff. Residents reported no evidence of abuse or staff not affording them dignity. Residents said they receive their medications in a timely fashion and had no complaints regarding receiving incontinence care or assistance with any Activity of Daily Living (ADL). The residents have not received complaints from other residents, nor have they witnessed any of the aforementioned allegations. Residents reported no complaints about anything related to the facility.

Staff interviews outlined the procedures staff follow when providing resident’s incontinence care. Staff are required to change residents at least four times a day when hospice providers come to the facility and administer care. Staff change resident undergarments and check for skin breakdown. As a practice, the facility staff does not document resident undergarment changes in the resident’s progress notes. However, outside source agency records did not show a lapse in incontinence care administered to residents. In regard to medications, staff denied making errors or delaying R1’s medications. R1 regularly took their medications but after 1/10/2024 began refusing them. Facility staff, as a practice, do not document when residents refuse to take their medications. Interviews revealed that on 1/11/2024, facility staff were directed by R1’s outside health services provider to hold certain medications due to R1’s change in condition.

Interviews with outside sources did not produce information to support the allegations. Outside agencies stated that they did receive cross reporting on the allegations in this complaint. No substantiated findings were determined by outside agency review of the allegations. LPA observation during a walk through of the facility did not show evidence that residents are not being changed regularly. Residents were fully dressed and showed no evidence to indicate they do not receive regular hygiene care and assistance. LPA observed no offensive odors; a common condition observed where residents are not receiving adequate toileting assistance.