Complaint Investigation Report

At 8:05am the administrator and LPA conducted a physical tour and health and welfare check of the facility and its residents. The LPA requested facility file documents pertinent to the investigation and noted further investigation was required prior to issuing findings.

Investigator Santiago conducted interviews on 07/05/2023, at approximately 11:49am, with the reporting party; on 07/27/2023, from approximately 9:47am to 10:55am, with Staff #1 (S1) and residents; on 09/05/2023, at approximately 9:47am, with R1’s resident representative; on 09/11/2023, from approximately 1:15pm to 2:15pm, with R1, licensee, and administrator; and on 09/15/2023, at approximately 11:30am, with American Medical Response (AMR) paramedic. In addition, the investigator reviewed incident reports, Marian Regional Medical Center medical records, and facility file documents related to the investigation. LPA Brian Phillips conducted record review and interviews into the other allegations.

According to R1’s physician report and preplacement appraisal information, R1 had diagnoses of depression, high blood pressure, and experienced lots of pain in arm and back. R1 had the capacity for all self-care. R1 was able to demonstrate the mental and physical ability to leave a building without the assistance of a person or the use of a mechanical device. R1 did not use a walker or wheelchair. R1 does not need help in transferring in and out of bed and dressing. R1 does not need help with moving about the facility. R1 did not require special observation/night supervision (due to confusion, forgetfulness or wandering). R1 can independently transfer to and from bed.

A review of R1’s incident reports revealed that on 06/16/2023, at approximately 10:00am, R1 was noted to be progressively more confused and with hallucinations. R1 was seen by the primary care physician for confusion about two weeks prior and labs were ordered to rule out urinary tract infection (UTI). R1 reported falling out of bed early in the morning as they rolled out of their bed. The incident report noted R1 is independent with their activities of daily living (ADLs) and is ambulatory without assistance. R1 was admitted to the hospital for further testing and UTI. R1 was discharged from the hospital on 06/18/2023. On 06/20/2023, R1 was noted to have a small bump on head in the early morning, was offered to go to the emergency room (ER) but refused. On 06/21/2023, at approximately 07:25am, S1 was surprised that the fire department was at the front door looking for R1. R1 called 911 without notifying S1. R1 stated they called 911 because they felt sick and weak.

According to the Marian Regional Medical Center medical records, R1 was seen in the ER on 06/21/2023 with the chief complaint of weakness. Continued on 9099-C