complaint·September 22, 2021

requesting Physical Therapy • Log for Checking on Residents every 2 hours for period 11/22/19 - 12/6/19 • Physician's Report • RCFE Resident Appraisal. The investigation revealed the following; Allegation: Staff failed to respond to resident's medical needs resulting in hospitalization. The details of the allegation states that on the evening of 10/18/19, R1's daughter called R1 and based on their conversation she determined that R1 was not in the right state of mind. R1's daughter called the reception desk in Independent Living asking staff to check on R1. According to R1's daughter, staff did not check on R1. The following day, R1's friend came to the facility and found R1 in her bed at 1PM unable to move or speak coherently. R1's friend called 911 and R1 was taken to the hospital. Based on the interview of LVN 2, LVN 2 could not recall receiving a call from the daughter of R1 asking to check on R1's condition. Staff interviewed stated that residents are checked each time a call is made by family requesting a staff member to check on a resident. Based on the interview of LVN 1, LVN 1 denied having knowledge of R1 not feeling well on 10/19/19. During her shift on 10/19/19, LVN 1 stated that she was surprised to see the paramedics arrive at the facility asking to see R1. LVN 1 escorted paramedics to R1's room finding R1 and R1's friend inside the room. According to LVN 1, R1's friend did not call staff for help and called 911 upon discovering R1 was not feeling her usual self. Based on interviews conducted, LPA learned that staff in Independent Living (IL) have a way of monitoring the IL residents. It's called "keeping an are you okay check" on the residents, which residents have to push the are you okay button (from their rooms) between the hours of 5am – 10am. If a resident fails to push the are you okay button by 10am, the computer generates a list of residents which staff will need to contact ensuring the resident well being. If there is no answer, staff will go in person and check on the resident in their apartment. In the case of R1, R1 had pressed the are you ok button in the morning alerting staff that everything was okay. During the interview of R1, R1 could not recall the incident other than waking up at the hospital on 10/19/19. In reference to her stay at Westminster Gardens, R1 stated that " this is a great place to live, staff Is helpful and the people are wonderful". Based on interviews conducted, there is insufficient evidence to support the allegation of Staff failed to respond to resident's medical needs resulting in hospitalization. Allegation: Facility staff failed to follow Physician's orders. The details of the allegation states the facility took three weeks to begin physical therapy. Based on the file review for R1 and interviews conducted, the following information was gathered. (Please see LIC 9099C for additional information) On 10/19/19, at 12:30PM, R1 was hospitalized at Methodist Hospital. On 10/25/19, R1 was transferred to Royal Oaks Skilled Nursing. On 11/22/19, R1 was transferred from Royal Oaks Skilled Nursing to Westminster Gardens Assisted Living, under respite care. On 12/6/19, R1 was discharged from Assisted Living respite care to her Independent Living apartment at Westminster Gardens. After reviewing the discharge instructions dated 11/22/19 from the treating physician, LPA discovered that there was no written order for physical therapy (PT) for R1. On 12/5/19, it is noted that R1 was visited by Concord Home Health and R1 will have a PT evaluation and treatment. Based on interviews conducted and record review, there is insufficient evidence to support that Westminster Gardens failed to follow physician's orders for PT in reference to R1. 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. An exit interview was conducted and a copy of this report was provided.