Complaint Investigation Report

R1’s physician’s report dated 12/05/2022 noted that R1 had a diagnosis of dementia, was identified as having confused/disoriented behavior, and was unable to manage individual aspects of care such as bathing, dressing, grooming, and toileting. Staff interviews confirmed that R1’s assessment was done in the presence of R1 and R1’s family. The staff whom completed R1’s initial assessment supported claims that R1 ambulated within their personal home without the assistance of a walker or wheelchair and noted that R1 did not require a walker or wheelchair at the time R1 was admitted to the facility. R1’s preplacement appraisal dated 11/29/2022 documented that R1 suffered from short term memory loss, was described as having obsessive behavior, anxiety, and had occasional mis-coordination with walking. The preplacement appraisal also noted that R1 occasionally ‘lies down but gets back up… confusion with bedtime’.

Staff interviews and a review of charting notes for R1 indicated that during R1’s first day at the facility, the staff mirrored R1’s routine that R1 established in their previous living arrangement to ensure a smooth transition. Charting notes indicated that R1 slept through the night on 12/27/2022, yet the morning of 12/28/2022, it was noted that R1 wandered the halls at 1:00 a.m. and that R1 was redirected back to their room. An interview was conducted with Staff #1 (S1), whom was the same staff on shift during the overnight shift on 12/30/2022. S1 claimed that during the night shift (10 p.m. on 12/27/2022 through 6 a.m. on 12/28/2022), they followed R1 while R1 ambulated through the community and re-directed R1 back to their room as needed. Throughout the day, on 12/28/2022, staff indicated that R1 was adjusting to the community. It was documented that R1 slept through the night that evening, leading into the morning of 12/29/2022.

Staff interviews and a review of charting notes revealed that on 12/29/2022, R1 was visited by their family. Staff whom worked during the shift claimed that soon after R1's family left the facility, it appeared that R1 wanted to leave with their family as R1 began attempting to exit the facility. Staff claimed that they implemented several interventions to attempt to re-direct R1’s exit-seeking behavior. Charting notes indicated that R1 was ‘very energetic and walked around the unit and exit sought’, and further noted that R1 had a hard time sleeping. Staff claimed that they tried several redirection techniques and methods to decrease R1’s exit-seeking behavior and attempted to implement R1's established nighttime routine but they were not effective. A review of R1’s Medication Administration Record (MAR) and an interview with medication technician whom worked the PM shift on 12/29/2022 indicated that R1 was provided with a ‘as needed’ medication of Trazodone at 7:14 p.m., due to the claim that R1 was having trouble sleeping. Staff notes and interviews indicated that the medication was not effective.