Complaint Investigation Report

Allegation: Facility failed to seek timely medical attention for resident in care:

It was alleged that Resident #1 (R1) fell while at the facility, resulting in a fractured femur and the facility did not send R1 to the hospital due to R1 receiving hospice services. Record review revealed that R1 fell on the following dates: 07/01/2021 resulting in a small abrasion to R1’s cheek, 07/03/2021 with no visible injuries noted, and 07/04/2021, which resulted in a bump to R1’s forehead, R1 “moaning with facial grimacing to touch and pressure to right leg.” According to the incident report and internal incident report, the fall occurred at 09:40PM. Hospice nurse notes dated 07/04/2021 indicate “called daughter and left voicemail. Gave option to bring to hospital or to keep [R1] comfortable at this time. Per [facility med tech,] [R1’s] daughter currently on vacation.” Internal incident report dated 07/05/2021 at 12:00AM indicates hospice “requested that [R1] not be sent to hospital because [R1] is admitted on hospice. A nurse will visit to reassess [R1] during daytime.” Additional internal incident report dated 07/05/2021 at 11:50AM indicates when staff arrived at the facility for the morning shift and was making morning rounds, R1’s “right hip was warm to touch and [R1] was screaming in pain.” Incident report further states facility staff called hospice, who indicated “working on trying to send a tech to get an x-ray done.” At 11:45AM, facility received a call from hospice giving authorization to call 9-1-1 and send R1 to the hospital. Progress notes dated 07/06/2021 indicate R1 sustained a right femoral fracture due to the fall that occurred on 07/04/2021. Although R1 is on hospice, the fall, which resulted in a bump on R1’s forehead and femoral fracture are not related to the expected course of R1’s terminal illness. As thus, regulations related to hospice care and informing hospice rather than calling 9-1-1 do not apply to the incident involving R1. Documentation provided reflects that R1 fell on or around 09:40PM on 07/04/2021 and although staff indicated R1 was “screaming in pain,” 9-1-1 was not called until 11:50AM on 07/05/2021. Therefore, based on interview and record review, the allegation that “facility failed to seek timely medical attention for resident in care” is deemed SUBSTANTIATED at this time.

Allegation: Licensee did not allow resident(s) to select their own health care provider:

The complaint alleges that the Licensee is forcing staff to refer residents to Aasta hospice and home health and forcing families to switch providers. During the course of the investigation, LPA spoke with family members of facility residents directly, as well as reviewed the list of providers, facility Admission Agreement, and a letter that was sent to residents’ families by the Administrator. According to the letter sent from the Administrator, Aasta’s hospice and home health preferred companies are as follows: Aasta Home Health