complaint·April 4, 2024

The investigation revealed the following: Allegation #1- Facility staff did not provide resident with water resulting in dehydration and hospitalization. The details of the complaint alleged that the facility did not take the time to regularly feed R1 because R1 was admitted to the hospital on 12/2/2022 and was diagnosed with dehydration and weighed only 83lbs. On 03/22/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R7) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 2 of 5 staff denied the allegation that Facility staff did not provide resident with water resulting in dehydration and hospitalization, while the other three (S3-S5) staff stated that they did not know the resident because the resident was not here when they were hired. S1-S2 stated that the resident was in hospice and had trouble eating and drinking fluids. S1 stated that R1 was on a liquid diet and fed through a syringe, and that they would give R1 ensure (meal supplement) and shakes but R1 would spit it out regularly, even with a syringe. S1 also stated that R1 was given water but that R1 would spit that out as well. S2 stated, “the resident was on hospice and steadily declining there was a problem with getting enough fluids in because R1 would spit out the food as well as water because R1 could not keep anything down for too long; maybe that is why R1 was dehydrated but it wasn’t that we were not giving R1 food and drink, R1 just had a hard time keeping it down. Additionally, in the physician’s report it states that the resident is under non-therapeutic measures which means we are to make the resident as comfortable as possible in the last stages of her life”. LPA interviewed R1-R7 about the allegation that the Facility staff did not provide resident with water resulting in dehydration and hospitalization. 6 of 7 residents that were interviewed stated that the facility gives them enough food and fluids throughout the day and have not had any issues with dehydration. LPA reviewed the preplacement appraisal, dated 04/26/2022, and it states that R1 has difficulty in swallowing and is on a pureed diet. Based on interviews and records reviewed there is insufficient evidence to support the allegation that Facility staff did not provide resident with water resulting in dehydration and hospitalization. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Report continued on LIC9099-C Allegation # 2- Facility staff did not provide resident with adequate amounts of food. The details of the complaint alleged that the facility did not feed R1 due to R1s low body weight and that the facility would only feed small portions of food to the resident. On 03/22/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R7) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 2 of 5 staff denied the allegation that Facility staff did not provide resident with adequate amounts of food, while the other three (S3-S5) staff stated that they did not know the resident because the resident was not here when they were hired. S1-S2 stated that R1 had difficulty eating and drinking and would spit out food and fluids regularly. They repeated that it was not that the facility was not feeding R1, they were, however because of her decline, R1 could not keep any food or fluids in R1’s system. LPA interviewed R1-R7 about the allegation and 6 of 7 residents that were interviewed denied the allegation that Facility staff did not provide resident with adequate amounts of food. Residents stated that they get enough food throughout the day and are satisfied with the care and supervision they are getting from the staff. Based on interviews, there is insufficient evidence to support the allegation that Facility staff did not provide resident with adequate amounts of food. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation # 3- Facility staff did not provide resident with adequate care for self-inflicted injury. The details of the complaint alleged that the facility did not change the residents’ dressing and had not cleaned the residents’ wound; causing an infection that happened when R1 had bitten R1s hand. It was reported that the wound was being treated by a wound nurse but when R1 was admitted to the hospital, it was infected. On 03/22/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R7) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 2 of 5 staff denied the allegation that Facility staff did not provide resident with adequate care for self-inflicted injury, while the other three (S3-S5) staff stated that they did not know the resident because the resident was not here when they were hired. S1-S2 stated that R1 had a history of biting R1’s hand. S1 stated that R1 had bitten R1’s two fingers on R1’s right hand and it had gotten infected. A wound care nurse was hired by St. Teresa Hospice to treat and care for the wound. S1 also stated that on 04/26/22, R1 was admitted to the hospital because R1 kept biting R1’s fingers and R1 would close R1’s mouth to keep them inserted. Report continued on LIC9099-C S2 stated that R1 had a problem with biting R1’s fingers and caused a wound. We let the hospice know and they sent a wound nurse that was treating R1’s injuries. When a family member heard of the problem with biting, the family member wanted to have all R1’s teeth removed but the doctor decided against that. Additionally, S2 stated that we monitored R1 closely, as did the wound care nurse who treated R1’s wounds. LPA interviewed R1-R7 about the allegation and 6 of 7 residents that were interviewed denied the allegation that the Facility staff did not provide resident with adequate care for self-inflicted injury. Residents stated that the staff are responsive and seek medical attention for them if they have injured themselves and take appropriate measures to get them help. LPA reviewed the preplacement appraisal, and it states the resident has a history of grinding R1’s teeth and biting R1’s fingers. Based on interviews, there is insufficient evidence to support the allegation that Facility staff did not provide resident with adequate care for self-inflicted injury. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation # 4- Facility staff did not seek timely medical attention for resident. The details of the complaint alleged that the facility did not seek timely medical attention for R1 because when R1 was admitted to the hospital R1 had an infected wound due to a self-inflicted injury and was diagnosed with a urinary infection that is believed to be caused by lack of food and water. On 03/22/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R7) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 2 of 5 staff denied the allegation that Facility staff did not seek timely medical attention for resident, while the other three (S3-S5) staff stated that they did not know the resident because the resident was not here when they were hired. S1-S2 stated that the resident received regular medical attention. There was a hospice care team, wound care nurse, and staff that assisted with the residents’ activities of daily living. LPA reviewed the LIC602A (Physicians Report) that showed the resident was incontinent and had a bladder impairment and bowel impairment, which can cause a urinary tract infection. LPA reviewed the Turning and Repositioning logs which showed the staff were changing R1’s incontinence briefs regularly. LPA interviewed R1-R7 about the allegation and 6 of 7 residents that were interviewed denied the allegation that the Facility staff did not seek timely medical attention for resident. Residents stated that they did not have any issues with the staff getting them timely medical attention when needed. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Facility staff did not seek timely medical attention for resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No deficiencies were cited. An exit interview was conducted with Ronald Libiran , Manager, and a copy of this report was provided .