Complaint Investigation Report

It was alleged that staff did not manage resident's care needs while in care. It was reported that R1 was not being provided with pain medication or hygiene care by the facility staff. Records reviewed and staff interviews revealed that facility staff provided R1 with showers twice a week. Upon R1’s admission to hospice care, the care plan was updated to include showers twice weekly, provided by the hospice nurse. According to the hospice care plan dated 01/07/2024, the hospice nurse was responsible for assisting R1 with hygiene, personal care, homemaking tasks, and providing showers twice per week. A review of the hospice flow sheet showed that R1 received either a shower or a bed bath from the hospice nurse on 01/08/2024, 01/15/2024, and 01/17/2024, indicating that the hospice team was not consistently following the care plan regarding hygiene and bathing. Interviews with facility staff also revealed that aspirin is typically prescribed as a routine medication rather than on a PRN (as-needed) basis. Staff stated that R1 was administered aspirin daily with morning medications until their doctor ordered the discontinuation of most medications, including pain medications, due to R1's difficulty swallowing. At that point, R1 was transitioned to comfort medications. The care plan further stated that the hospice nurse was responsible for assisting with pain and symptom management, assessing vital signs during each visit, and reporting any unrelieved pain despite rest and prescribed medications. Additionally, documentation from an outside agency / hospice notes dated 01/08/2024 indicated that R1 showed no signs of pain or distress during the hospice nurse’s visit. Furthermore, interviews with five out of five residents revealed no concerns regarding the administration of their daily medications. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not manage resident’s care needs while in care”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was also alleged that staff handled resident in a rough manner. It was reported that staff were observed grabbing Resident 1 (R1) roughly while providing care. Interviews conducted with staff revealed that no residents had reported being handled inappropriately or too roughly while receiving assistance. Additionally, staff stated that residents regularly communicate with their family members, and no complaints have been received from families regarding rough handling. Interviews conducted with residents indicated that they had not observed staff handling other residents roughly, nor did they feel that staff were too rough when assisting them.