complaint·January 26, 2023

Continue from LIC9099 Staff did not ensure resident had sufficient liquids. The Hospice care plan was reviewed, and it was found that hospice advised the facility to honor R1s refusal of food & liquid. S1 reported (corroborated by W1) that the facility was providing liquids such as, juice, coffee, water and milk. Fresh juice was provided by family. W1 also stated that R1 would take small sips of liquid as much as she could tolerate due to her condition. Staff dispensed wrong dosage of medications. R1’s medication administration record indicated all medication was given as prescribed. S1 reported that R1 was never given an incorrect dose of medication. W1 reported having been with R1 throughout the time R1 was at the facility, and that there were no medication errors. Further, W1 reported that W2 was also present during medication rounds and reviewed with the hospice nurse R1s medications when administered. S2 and S3 (who had assisted R1) denied any knowledge of a medication error. Facility serves low quality food. A tour of the facility was conducted and the facility was observed to have a minimum of 2-day perishable and 7-day non-perishable food supply, including fresh fruits and vegetables, cereals, bread, juice, milk, water, coffee, and meats. The facility menu which indicates a variety of meals are planned. W1 observed and reported having no issues with the quantity and quality of the food, stating that R1 could consume little food and liquid – as stated in the hospice care plan. S3 reported that all meals were provided to R1 but that she could tolerate little food and drink. S3 also reported that W1 also attempted to food R1. Continue on LIC9099C Continue from LIC9099C Facility Staff slapped resident. W1 which reported being by R1’s side the entire stay at the facility and that no caregiver had ever slapped R1. W1 stated that 2 caregivers took good care of R1. The two caregivers that assisted R1 were interviewed: S2 reported never having slapped or witnessed anyone slap R1. S2 reported that R1 was served all meals and liquids but she did not eat because she was weak and fragile. S3 reported that she did not slap or witness any coworkers slap R1. Based upon records review, interviews conducted, and observations made, the Department has investigated the above allegations and found that they are Unsubstantiated. A finding that the complaint allegation/s are 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 a copy of this report provided