Complaint Investigation Report

Complaint alleges facility is not meeting resident's care needs. Per review of records, resident was admitted to facility 2/20/2024 during a transitional time regarding their healthcare team. There were multiple changes in the persons providing care or assigned to the resident’s healthcare team. Resident is pre-diabetic and requires a consistent controlled carbohydrate (CCHO) and mechanically soft diet. Resident is non-ambulatory and requires assistance with ADLs, with the exception the resident is able to feed themselves. Per record review, facility has monitored blood sugar of resident beginning the day after admittance. Interviews with staff indicate an initial lack of clarity by resident’s healthcare team in regards to what actions need be taken if the blood sugar is too high or too low. Licensee requested clarification from resident’s healthcare nurse and received instruction as of 3/23/2024. On 3/27/2024 licensee held training with staff and made a chart for them specific to resident, as to an action plan regarding blood sugar readings. Record review shows that the resident was to receive a shower or sponge bath on Tuesdays, and a shower on Fridays. Record review shows that resident refused showers on a regular basis. Resident is not ambulatory and works with physical therapy to regain ambulatory status. Per interviews with staff and outside party, resident is often resistant to physical therapist’s suggestions for activity. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.