complaint·February 27, 2024

Allegation: Staff placed a resident on hospice against their wishes. According to information obtained, resident (R1) was "fraudulently" placed in hospice care and had fluids removed against their will. It is alleged that R1 had a recent stroke, but was still able to communicate with hand gestures i.e., hand squeezes and in writing, but no one asked the resident what they wanted. Resident (R1's) advocates asked the facility to restore fluids but the request was not addressed. Per record review, R1 was sent out to the hospital on February 2, 2024 for a urinary tract infection (UTI). The resident was then transferred to a skilled nursing facility, where R1 had another stroke. A total of four (4) staff were interviewed, of which all stated that R1 has a Power of Attorney (POA), who made the decision to enroll the resident in hospice care while the resident was at a higher level of care facility, and prior to returning to the facility on February 19, 2024. Resident (R1) was enrolled in hospice care the same day he returned to the facility. The resident's diet was "NPO", nothing by mouth, "mouth moistening swabs only". The facility presently has 2 other residents enrolled in hospice and both had cognitive impairment and were unable to respond to the questions. Based on record review of the most recent Physician's Report dated 2/19/24, the MD noted hospice care was needed due to permanent CVA and dysphagia. In addition, R1 has an Advance Health Care Directive effective 1/17/2009, appointing their Power of Attorney (POA), "Not to prolong life" and a POLST dated 8/18/2023, that states "no artificial means of nutrition, including feeding tubes". A 2nd POLST was updated on 2/18/24 by POA and signed by MD on 2/21/2024, to "Comfort-Focused Treatment". Therefore, the findings indicate that the POA placed R1 in hospice care. Therefore, the facility followed the POLST, Advance Directive, and POA's decision to initiate hospice service. NOTE: The facility received a phone call from hospice agency reporting that R1 passed away today. Allegation: Staff are not following a resident's legal documentation. It is alleged that the facility is violating the resident's rights by following resident (R1's) family member's decisions without having Power of Attorney. Based on record review, the resident moved in on 11/30/2023 and an a copy of an Advance Healthcare Directive dated 1/17/2009 was provided, along with a POLST signed by R1's legally recognized decision maker. All staff interviewed denied the allegation and stated that the facility obtained legal documents appointing R1's sister as the Power of Attorney for healthcare decisions. The findings indicate, there is no merit to the allegation, because R1's file has all legal documents pertaining to healthcare decisions, and the facility is adhering to the stipulations noted on the documents. 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 with Executive Director Sanjay Kabadi. A copy of the report was issued.