complaint·January 17, 2023

Questionable Death. On 6/27/22 W1 decided to move R2 back to her home so she could monitor his care more closely. While moving R2 from his bed to a wheelchair he collapsed. The hospice nurse told S1 to call 911. S1 did so and then left R2’s room to retrieve his POLST from her office. When S1 returned to R2’s room the paramedics had pronounced R2 deceased. Facility administered medications to resident without physicians order. Facility mismanaged medication resulting in overmedicating resident in care. S1 stated that all medications for R2 were handled by either W1 or the hospice nurse. LPA reviewed R2 medication orders on file and MARs from 5/31/2022-6/27/2022. No medications were administered by facility staff. All medications listed on the MARs were initialed by staff as “given to family to give later” and matched physician orders on file. W1 could not recall which medications were administered without the proper order nor which date said medications were taken by R2. Personal rights- resident spoken to inappropriate manner. Personal rights- facility staff handled resident in a rough manner. Both S1 and S2 stated that they never saw any staff members at the facility speak to R2 in an inappropriate manner or handle R2 roughly. Responsible party not notified about resident's change in condition. Both S1 and S2 stated that they were in constant contact W1 regarding her father’s condition. Both S1 and S2 showed LPA numerous text messages on their phones to and from W1. Staff unable to communicate with residents due to language barrier. S2 stated that some of the housekeeping staff speak very little English but that they are not responsible for resident care. Care staff all speak English. ***Report continues on LIC9099C** ***Report continues from LIC9099C*** Lack of supervision- resident sustained several unwitnessed falls with injury. LPA reviewed R2’s SIR’s and there was no documentation of any falls. S1 stated she never was told by staff that R2 had fallen. This agency has investigated the above allegations. Based on records reviewed, and interview conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted and a copy of this report provided.