Complaint Investigation Report

Based on the NPNs report noted for 071724, 071924, and 072324, staff assisted R1 with transferring in and out of bed.

On 06/10/24, R1’s medical and health condition changed. R1 was noted to have an unsteady gait due to weakness, which resulted in his/her inability to stand and walk. R1 was admitted to a Skilled Nursing Facility (SNF) for rehabilitation, where R1 was evaluated by a Physical Therapist (PT) on 07/02/2024. R1’s DPOA (Duly Power of Attorney) was aware of R1’s change of condition.

On 07/05/2024, R1 was admitted back to the facility from SNF but was later sent to the hospital, on 07/05/2025, due to being unresponsive or unarousable to stimuli. After 07/05/2024, R1’s change of health/medical condition, including level of care, became more apparent, such as but not limited to R1’s inability to reposition in bed, including transferring from/to bed/wheelchair, increased body mass, and shortness of breath (SOB).

On 07/22/2024, R1 was seen by his/her Occupational Therapist (OT), who documented that R1 was asleep in bed, could not stay awake, was wheezing, was unresponsive, was not following commands, and was completely bedbound.

On 07/24/2024, R1 was seen by a physical therapist (PT) who recommended the initiation of hospice services as an option to R1’s DPOA. It was unclear whether R1’s DPOA agreed to the recommendation of the hospice services.

Lastly, on 07/25/2024, R1 was sent to the hospital due to staff observing R1 to be less responsive and was cold touch with chest congestion.

On 04/02/2025, LPA obtained and reviewed R1's Care Plan for 07/05/24. The goal was to safely transfer R1 t/from bed/wheelchair. The plan was to obtain PT/OT home health for lower extremities strengthening. If R1 requires more than 2 people to transfer, then leave R1 in bed and provide care services to R1 there, including repositioning every 2 hours to avoid pressure injury and maintain skin integrity. Call 911 if R1 appeared in distress during transfers.

Based on LPA's overall review of R1’s care plan, R1 had been experiencing physical and cognitive decline, with suspected water weight gain, and had become unresponsive. Staff attempted to assist R1 out of bed daily with 2-person assistance to transfer R1 from bed to wheelchair and leave R1 in bed if 2 staff members were not able to hold R1’s upper extremities and move his/her lower extremities at the same time during the transfer.