Complaint Investigation Report

It was alleged that the staff did not address resident (R1)’s change in condition starting around 05/11/2024 as necessary as on 05/13/2024, R1’s responsible party had to instruct the staff to check R1’s vitals and send R1 to the hospital after realizing something was wrong. On 05/13/2024, R1’s responsible party received a text from the Administrator regarding R1's condition.

Based on record review, on 05/11/2024, there were no notes regarding a change of condition for R1. On the morning of 05/12/2024, it was stated that R1 was encouraged to shower but R1 refused. R1 claimed that he/she could not breathe and staff asked if R1 would like to use his/her inhalation assistive device. It was noted that R1 called his/her father "claiming" he/she is heavy coughing.

On the morning of 05/13/2024, it noted that R1 was coughing and did not attend day program. R1 stayed in his/her room laying in bed and refused to eat / shower. In the afternoon, R1 refused to eat. It’s noted that R1 kept on insisting that he/she was sick.

The review of the text message exchanges between the Administrator and R1’s responsible party shows that on 05/13/2024 at 3:44PM, the Administrator sent a text to R1’s responsible party stating that R1 did not attend day program and refused to shower for 2 days. The Administrator did not mention that R1 refused to eat and was coughing. R1’s responsible party replied to the Administrator by questioning if R1 had a fever. The Administrator replied but did not answer the question on if R1 had a fever. R1’s responsible party then asked the Administrator for R1’s oxygen level and temperature and begged that the Administrator check for all R1’s symptoms as R1 is unable to articulate his/her source of pain. The Administrator again replied but did not answer the question of R1’s oxygen level, temperature, and symptoms. R1’s responsible party again asked the Administrator for the third time of R1’s oxygen level and temperature, in which then the Administrator sent a picture of R1’s vitals.

Based on record review of R1’s vitals (oxygen, temperature and blood pressure), staff began recording R1’s vitals starting at 6:40PM where it was noted that R1’s oxygen level was at 93 (6:40PM), 85 (8:00PM), 85 (9:30PM), and 94 (8:55PM). PAGE 2 OF 3.