Complaint·March 18, 2024

Allegation #1: Staff did not provide medical assistance to resident while in care. It is alleged resident #1 (R1) had a medical emergency at the facility, and staff did not seek medical attention. To investigate this allegation LPAs Joscelyn Martinez and Tuesday Cabiness conducted an initial complaint investigation on 05/17/2022. They interviewed four (4) residents including R1, interviewed staff present and reviewed and obtained resident records. Interview with residents on 05/17/2022 and 03/18/2024 revealed they are satisfied with the assistance being provided and are confidant staff can determine if they are having a medical emergency and will call 911 if needed. Interview with staff on 03/18/2024, staff denied the allegation and revealed R1 may seek attention sometimes and or omit information from staff later revealing they may have been experiencing symptoms from medication. Interview with staff on 05/17/2022 revealed on day in question staff was present and according to them R1 had reported shortness of breath but then stated they were ok. According to staff they contacted R1's relative and they insisted R1 be taken to the hospital. Discharge paper work obtained by LPA Martinez revealed R1 was recommended a medical procedure. Interview with R1 on 05/17/2022 revealed on the day in question they had complained about shortness of breath but that it was not true. When LPAs asked why R1 stated so, R1 stated they wanted to get out of the facility because they felt stuck there. R1 went on to state they did not feel ill and were not experiencing any symptoms. Based on information obtained through interviews and record review this allegation is deemed Unsubstantiated at this time. Allegation #2: Staff did not administer medication to resident while in care. It is alleged facility failed to provide medication during the time R1 was discharged from Hospice. To investigate this allegation on 05/17/2022 LPAs review of Medication Administration Records (MAR) for the time period in question revealed medication listed on MAR was provided. Interviews with four (4) residents on 05/17/2022 and four (4) out of four (4) residents on 03/18/2024 revealed they cannot recall ever experiencing missed medication, or medication errors. According to interview on 03/18/2024 with staff responsible for assisting residents with medication they deny the allegation and they state they have always provided medication as directed. On 03/18/2024 LPA's review of R1's physician's report for examination done on 06/24/2022, revealed R1 was not receiving Hospice care and a terminal illness was not specified. According to a telephone interview with Administrator on 03/18/2024, R1 was discharged from Hospice and not receiving Hospice care for about two years. Administrator states R1 is now receiving Hospice care. LPA's review of R1's Hospice records revealed last entry was made on 05/20/2021 for a medication that LPA reviewed on MAR was documented as being provided during period in question. Based on information obtained through interviews and record reviews this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report signed and delivered.