Complaint Investigation Report

Interviews conducted also stated that R1 could be combative towards staff when being provided care. Interviews stated that facility protocol for incontinence care was to check on residents every two hours. Records reviewed showed that facility documented when R1 would refuse care. Records reviewed also showed that a Care Conference meeting between the facility and R1’s responsible parties dated 01/15/2022 addressed the noted concerns. Based on Interviews conducted, Review of Facility Documents, and Review of R1’s Physician’s Report, Physician’s Orders, and MAR, the LPA is unable to determine if the facility failed to meet resident’s needs, therefore this allegation is Unsubstantiated.

There is an allegation that Facility staff neglected in care resulting in resident hospitalization. Report dated 04/01/2022, stated that on 03/24/2022, R1 was found on the facility patio by family and was observed to be left out in the sun with no water or supervision. Review of R1’s Hospital Visitation Records for 03/24/2022 stated that per Emergency Personnel Services (EMS), R1 was unresponsive for approximately 10 minutes but was at their neurocognitive baseline by time of EMS transport. Upon arrival to hospital, R1 was found to have an initial diagnosis of hypothermia. A Review of R1’s Discharge Summary dated 3/31/2022 stated that the Hospital’s Principal diagnosis for R1 was Syncope. Attempts to retrieve Emergency Personnel Services (EMS)/Paramedic reports to review R1’s observed condition before and during transport to the hospital were unsuccessful. Staff interviews conducted stated that R1 was out in the sun for no longer than 10-15 minutes and was able to ambulate appropriately when asked. Interviews stated that R1 wanted to stay outside and became combative when facility staff tried to get R1 to come inside. Interviews also stated that facility would provide sun hats for residents and ensure they stayed in the shade when the sun was out. Staff would also remind residents to use the hydration stations available on the patio for water. During visits conducted on 4/20/2022 and 7/1/2022, LPA observed stations of water available for residents on the patio. Records reviewed stated that on 03/24/2022, R1 was still responsive while waiting for EMS to arrive and all R1’s vitals taken before transport were normal. Review of Facility Incident Report submitted to Community Care Licensing (CCL) dated 3/31/2022, indicated that the Incident occurred at 10:30AM on 03/24/2022. Per weather website, www.timeanddate.com , the temperature during the incident time was approximately 73 degrees F. Program Clinical Consultation Report dated 10/03/2022, was not able to come to a determination if R1’s diagnosis of Syncope was related to being outside on the patio.