Complaint Investigation Report

a result of this, it shows a lack of good judgment used by staff in dressing a resident inappropriately for the weather. The allegation is Substantiated, but a Technical Violation is issued in lieu of a citation.

On the allegation: Facility did not arrange timely medical attention for resident. LPA reviewed text messages between RP1 and the Licensee. Based on interviews with RP1 and the text message records, on 9/5/2022 at 1:12 pm, Licensee acknowledged receiving text messages from the day before showing a large bruise on R1’s left arm. RP1 expressed concerns about the bruise on R1’s left arm and wanted R1 seen by hospice to assess if further medical treatment was needed. Licensee stated they texted the photos to R1’s hospice nurse. Licensee stated they were not sure what time the hospice nurse was coming that day and asked RP1, “Can you call [the hospice nurse] directly as well and try and find out her schedule.” Licensee also forwarded contact information for the hospice nurse to RP1. At 1:59 pm on 9/5/2022, RP1 texted Licensee the hospice nurse “will be there shortly.” The Licensee and facility staff should have sought medical attention for R1, rather than instructing a resident’s family member to do it. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Facility failed to notify resident’s authorized representative of bruising. RP1 visited R1 on 9/4/2022. R1 was wearing a long sleeve shirt even though it was a very hot day and the inside of the facility was also very warm, around approximately 85 degrees F. RP1 helped R1 change into a short-sleeved shirt and did not notice any bruising. RP1 visited R1 again on 9/5/2022. RP1 noticed R1 was wearing the same shirt from the day before that RP1 put on R1 and noticed a large bruise on R1’s left arm. RP1 provided photographs of the bruise to LPA. LPA observed bruising large in size on R1’s left arm, from the lower shoulder area down to almost the elbow. LPA noted the bruise is darker toward the bottom and is a lighter color at the top. RP1 asked the Care Director about the bruise, and the Care Director admitted knowledge of the bruise. Care Director stated she texted all the caregivers to ask about the bruise, but no one knew what happened. RP1 asked Care Director why RP1 was not contacted about the bruise, and the Care Director stated the Licensee knows about it. LPA reviewed a text message from 9/4/2022 from the Licensee/Administrator to R1’s hospice nurse. The text shows a screenshot of another conversation between the Administrator and a staff, reflecting a picture of the bruised arm with the staff stating they just looked at R1’s arm and R1 had a big bruise on the left arm. The text states it is green on the upper part and purple on the lower part of the arm. The Administrator sent a text message to the hospice nurse that the bruise was observed for the first time that day and none of the staff were sure how R1 received the bruise. The investigation revealed staff and Administrator/Licensee observed the large bruise on R1 on 9/4/2022 but did