complaint·March 24, 2022

On 12/16/2020, between 11:00 a.m. and 11:45 a.m., LPA Miller conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically. LPA conducted an interview and physical plant tour via video chat with facility administrator Judith Muro. LPA requested copies of pertinent documents relevant to the investigation and noted further investigation would be required. During LPA Camara’s visit to the facility on 03/04/2022 between 9:47 a.m. and 11:47 a.m., LPA interviewed the administrator at 9:47 a.m., staff 1 at 10:42 a.m. and staff 2 at 10:46 a.m. LPA obtained pertinent documents and conducted a brief facility tour at 11:18 a.m. LPA also conducted a telephonic interview with staff 3 at 3:33 p.m. During LPA Camara’s visit to the facility on 03/11/2022 between 11:35 a.m. and 12:28 p.m., LPA interviewed staff 4 at 11:07 a.m. and staff 5 at 12:15 p.m. as well as obtained more documents. LPA also conducted a collateral visit with R1’s physician on 03/11/2022 between 1:00 p.m. and 2:18 p.m. The administrator and staff stated that other than going to the dining room for meals, R1 stayed inside their single occupancy room. R1’s room was equipped with a television which R1 enjoyed watching and R1’s family sent care packages of snack foods which R1 also enjoyed. R1 was friendly but did not have any close friends at the facility. R1 only had one family member who would occasionally visit. R1 did not require assistance with activities of daily living. R1 did receive medication management. Staff stated that since R1 was mostly independent, when they would check on R1 they would knock on the door for permission to enter R1’s room. Staff stated R1 was last seen at approximately 5:00 p.m. on 12/09/2020, watching television in R1’s room. R1 said goodbye to the staff who checked in as they were leaving for the day. Staff observed R1 was lying in bed watching television; R1 had no complaints. Other staff indicated R1 never complained about not feeling well or anything else; R1 was a very pleasant person. On 12/10/2020, at approximately 08:00 a.m. staff were concerned because R1 had not come to the dining room for breakfast which was very unusual. Staff knocked on R1’s door and when there was no answer, they used a key to unlock R1’s door. It appeared R1 had been sitting on the side of the bed as R1 was found fully clothed and laying across the bed, deceased. Information gathered reflected R1 was initially admitted to the facility on 08/28/2017 from another assisted living facility. R1’s physician’s report used for admission was from a physician in Hudson, New York dated (continued on 9099-C) 03/23/2015. Physicians’ reports in the facility records for R1 were dated as follows: 09/17/2018, 10/09/2019, and 10/07/2020 all completed by R1’s primary treating physician. R1’s physician also examined R1 on the following dates: 10/04/2019, 06/12/2020, 07/16/2020, 10/11/2020 and 11/02/2020. According to R1’s physician, R1 visited his office on 10/04/2019, the other visits occurred at the facility. During the 10/04/2019 visit an electrocardiogram (ECG) was performed as well as a blood draw for lab work. The ECG showed R1 had suffered two prior heart attacks: one significant and one minor. R1 had no recollection of suffering previous cardiac events. R1’s physician stated R1’s lab results showed R1 appeared to be diabetic. R1’s physician explained it is not unusual for a person with diabetes to not feel chest pain; it is known as a silent heart attack. R1’s physician encouraged R1 to eat healthier and exercise. R1 was told to return to the physician’s office after fasting so more blood work could be obtained, and the physician could determine what type of diabetes medications to prescribe. However, R1 never followed through with getting fasting blood work done. R1’s physician stated R1 was capable of following up on medical appointments. R1’s physician was unaware of R1 having any family involved in her medical care. R1’s physician stated the lack of blood work did not cause R1’s death. R1 was taking two blood pressure medications. Staff who handle making medical appointments did not recall any requests from R1’s physician for fasting blood work. R1’s physician sees several residents who reside at the facility and has an office in a small room on the first floor of the facility. If the physician wants staff to follow up on something like appointments for blood work, the physician notifies one of the medication technicians. However, some of the physician’s patients handle their own follow up medical care needs. During the time surrounding R1’s death, the facility had an outbreak of COVID-19. R1 had a PCR test done on 12/06/2020 and tested negative for COVID-19. The death certificate indicated the immediate cause of death was acute myocardial infarction with underlying causes listed as hypertensive arteriosclerotic heart disease, diabetes mellitus, hyperlipidemia, and obesity. Based on the medical records, staff interviews and an interview with R1’s physician, it does not appear that lack of following through with blood work led to R1’s death. There is insufficient evidence to confirm that R1’s death was due to facility staff neglect; therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of the report issued.