Complaint Investigation Report

Staff neglect led to hospitalization of resident:

Staff did not seek medical attention for a resident in a timely manner:

The facility was alleged that staff neglect and led to R1's hospitalization, and staff did not seek medical attention for R1 in a timely manner.

Resident R1 was admitted to the facility on 04/28/2023. R1 was able to ambulate with cane and was able to feed self.

On 05/31/2023, R1 was tested COVID positive and was isolated in his/her room. As R1's COVID progressed, R1 was getting weaker. R1 was unable to feed self without staff assistance and was unable to ambulate.

On 06/21/2023, two friends of R1' family member visited R1 and found R1 was weak and was unable to get out of bed. R1's visitor called 911 when R1's visitor visited R1.

Based on the interviews conducted on 11/06/2023 and 11/14/2023 with Executive Director, Director of Resident Care Services, and the charge nurse, Executive Director and Director of Resident Care Services

admitted that staff did not follow protocol regarding R1' change of condition and did not read the staff notes from the previous shifts regarding R1's condition. Staff S1 admitted that he/she did not read the staff notes from the previous shifts and that based on the previous staff notes, R1 should have been sent to hospital based on R1's declining condition.

Staff documented R1's change of condition but did not report R1's change of condition to Executive Director or Director of Resident Care Services.