Complaint Investigation Report

Between 4/26/2022 through 6/2/2022, 7 staff were interviewed. 6 out of 7 stated R1 was observed to be weak, not wanting to get out of bed, went 24-48 hours without eating and constipated for two days prior to being sent out to the hospital. 1 staff stated R1’s doctor/nurse practitioner (NP) was contacted on the day when R1 was sent out to the hospital.

R1’s nurse practitioner (NP) was interviewed and stated facility left a voicemail on 4/25/2022 stating R1 had not had a bowel movement or eaten in 48 hours. When NP called back, R1 was already at the hospital.

A copy of R1’s Medication Administration Record (MAR) was obtained. The review of the MAR noted the entry for 04/23/2022 stated R1 was given medications (names of meds not stated) in the morning, at 4PM, and 8PM. The entry for 04/24/2022 stated R1 was given medications (no names of meds stated) in the morning, but not at 4PM or 8PM. There was a handwritten note on the entry that stated: “Pauline was not eating. We did not give meds bc of this. Just giving fluids.”

R1’s Documentation Survey Report for April 2022 includes a Meal Consumption log was obtained and reviewed. The entry for 04/21/2022 stated R1 ate 75%-100% at 8AM, 12PM, and 5PM. The entry for 04/22/2022 stated R1 refused meal consumption at 8AM; there was no entry for 12PM; the 5PM entry stated R1 consumed 75%-100% of a meal. The entry for 04/23/2022 has no entry for 8AM and 12PM; the 5PM entry stated R1 ate 75%-100% of a meal. The entry for 04/24/2022 stated R1 refused meals at 8AM and 12PM and ate 0-25% of a meal at 5PM. There was no documentation from R1’s doctor/NP to order medications be stopped due to not eating. Neither was there documentation that R1’s POA was notified regarding R1 not eating for 48 hours.

A copy of R1’s LIC602 Physician’s Report was reviewed and noted R1 has a diagnosis of dementia and type II diabetes and has bowel and bladder impairment. It was noted that R1 is able to feed self, but meal set up is needed.

On 04/26/2022, Admin called Licensing Program Analyst (LPA) stating that Admin had conducted a reassessment of R1 over the telephone with hospital personnel and that given R1’s fecal condition and the need for acute care for R1’s diabetes, the facility staff cannot assist R1.

See LIC9099-C for more information. Page 2 of 5.