complaint·December 17, 2024

Page 2 Allegation: Resident (R1) lost a large amount of weight while in care. FM stated R1 lost 40 lbs while in facility’s care. Two of the 9 staff who provided care to R1 were interviewed. These 2 staff stated they noticed R1 losing weight but R1 at times refused to eat. When R1 refused to eat, they either changed the food, provide options or switch caregiver. Two facility LVNs and facility RN stated if resident lose weight they inform the resident’s primary care physician. Review of medical records showed that prior to R1’s passing away, R1 had appointments with medical professional of which FM brought up the issue of R1 losing weight; however, R1’s weight was not recorded due to the visits were virtual. On 4/07/21, the medical professional sent correspondence to the facility and requested to send R1’s weekly weight record. Weekly weight records from 4/05/21 to 7/23/21 ranged from 112 lbs to 120 lbs. LIC602A dated 5/04/21 showed R1 weight was 118 lbs. LPA was not able to interview R1 as R1 was no longer at the facility when complaint was received. Therefore, the allegation is unsubstantiated. Allegation: Facility did not contact resident's (R1) representative on status of resident's health. FM stated that on 8/03/21, day prior to R1 passing away, FM went to the facility and found R1 unresponsive with sunken cheeks and mouth open, and that the facility did not inform FM. Review of records showed that prior to R1’s death, facility’s hospice visit note dated 8/03/21 showed hospice agency staff were at the facility with FM. All 3 caregivers interviewed stated if there’s a change in resident’s condition, they inform the facility med-tech and/or nurse. All 4 facility nurses including Director of Resident Care Services (DRCS) stated they inform the resident’s family/responsible person and primary care physician (pcp) of the changes in resident’s conditions. DRCS also stated she conducts care conference with the resident's family and/or responsible person to discuss and let them know that she will contact the pcp. One of the facility nurse (S2) stated that if resident is on hospice and actively dying, they call hospice staff and resident's family to inform of the change in condition. Resident (R4) stated that the facility staff are good in providing update for him and his wife who is also a resident of the facility. Therefore, the allegation is unsubstantiated. .....continued on 9099C (page 3) Page 3 Allegation: Facility did not adhere to the resident's care plan. FM stated that it is in the care plan that staff agreed to weigh R1 regularly, but this did not happen. FM also stated the staff were not giving R1 pain pills and that FM fought to have staff continue the pain management. All staff interviewed stated that residents in the Memory Care are weigh every month. R2’s husband stated that R2 is weighed every month. Review of R1 record showed that on 4/07/21, R1’s medical professional sent correspondence to the facility and requested to send R1’s weekly weight records. Records from 4/05/21 to 7/23/21 showed R1 was weighed once a week. Review of resident’s record showed there were changes over time in R1’s doctor’s order of pain medications and the medications were administered. Therefore, the allegation is unsubstantiated. Allegation: Resident did not receive medical care in a timely manner. FM stated that on 8/03/21 FM came to the facility and found R1 unresponsive, with sunken cheeks and mouth open. R1 was taken to the hospital and died on August 4, 2021. FM also stated that FM believes that R1 should have been taken to the hospital sooner. Review of records showed R1 was placed and admitted on hospice care on 7/02/21 due to advanced dementia and failure to thrive. Staff interviewed stated that if resident is on hospice and actively dying, they call the hospice agency unless the resident fall or sustained head trauma, 9-1-1 is called. Records showed R1 was visited by hospice on the following dates: 7/06/21 to 7/09/21; 7/14/21 to 7/23/21; 7/26/21 to 7/30/21; 8/03/21. Death Report showed R1 passed away on 8/04/21 and death certificate showed senile degeneration of the brain as cause of death. Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegations are found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and copy of this report provided.