Inspector’s narrative
What the inspector wrote
of blood and bleeding from the head on 12/07/22 at the facility. It was unclear how long R1 was laying on the floor.
·
02/27/23: Interview with the facility administrator, Jonathan Perles confirmed R1’s admission in 2015, and acknowledges R1’s fall on 12/07/23. Interview with R2 confirms R1’s fall, but R2 could not recall much details of the incident. Interviews with Staff 1 (S1) and Staff 2 (S2) confirm R1s fall on 12/07/23, at approximately 3:00am, confirms the presence of blood to the forehead of R1, confirms cleansing and a band aid only applied, confirms that R1 was not sent to the hospital until 4:00pm on 12/07/23. Interviews with staff also confirmed that R1’s responsible person(s) was not notified of R1’s fall, but only of the hospitalization.
Although Staff was made aware of R1’s fall at approximately 3:00am in morning of 12/07/22, and only basic first aid was applied, staff did not seek the medical attention for R1 until 4:00pm that afternoon. Furthermore, a review of R1’s medical records indicate that since October 22, 2022, facility staff had knowledge of and acknowledged that R1’s cognitive and physical condition had progressed, continued to decline, and required assistance with hydration to prevent an infectious disease (sepsis), which caused R1’s brain to malfunction and experience a dysfunction that altered consciousness and behavior. Therefore, based on the information obtained, the allegation is
Substantiated.
Citation(s) issued on the 9099D.
Exit interview conducted. A copy of this report and appeal rights issued.
Based on the information obtained by IB, it could not be proven that staff’s neglect could have led to R1’s severe dehydration. Therefore, the allegation is deemed
Unsubstantiated
at this time.
The following allegations were investigated by LPA MIchael Cava on 03/09/24:
Resident wandered away from facility due to lack of supervision/Staff did not notify responsible parties of a resident's unexplained absence from facility:
In regards to the allegations, it was reported that R1
has been lost due to wandering multiple times for hours, but family was never notified by facility staff. There were no dates specified on when and how many times R1 has wandered away from the facility. Investigation to these allegations consisted of interviews with staff and record review. LPA was only able to identify one staff, Staff 1 (S1) who recalls when R1 resided at the facility. R1 moved out of the facility on or around June 2023. According to S1, R1 and their spouse Resident 2 (R2), never really left their room. Both residents had their meals delivered to their rooms. Both residents never participated in facility activities. Review of both R1 and R2's records reveal that both residents are ambulatory and able to leave the facility unassisted. Also review of facility incident reports for R1 and R2 show no record of either residents wandering away from the facility. Based on the information obtained, there wasn't enough evidence to prove R1 wandering away due to lack of supervision, nor staff not notifying R1's responsible person of the unexplained absences. Therefore, the allegations are deemed
Unsubstantiated
at this time.
Staff failed to administer residents medications as prescribed:
In regards to the allegation, it was reported that
facility staff is supposed to check and assist R1 with medications as needed but failed to do so, for so long that it resulted in an infection. IB's investigation reveal that R1 is an independent individual. LPA's review of of R1's file reveal that R1 has the capacity for self care, which includes the ability to manage own medication, administer own prescription and PRN medication, and able to store own medications. Furthermore, there is signed documentation in R1's file, which indicates that R1 has read and understood their responsibility in keeping all medications stored in a lock box at all times, which would be the only way that R1 will be able to self medicate, control and maintain their medications. R1 was advised failure to do so will be in violation of Title 22 and Evergreens rules and regulations, subject to losing their right of self administering their medications. Signed and dated R1 on 06/14/18. A review of facility incident reports for R1 show no record for any medication error/management, which could have resulted in and infection and/or hospitalization, during their stay at the
facility. R1 moved out of the facility June 2023. Based on the information obtained, there was insufficient evidence to corroborate the allegation of Staff failing to administer R1's medications as prescribed. Therefore, the allegation is deemed
Unsubstantiated
at this time.
Staff stole resident's belongings:
In regards to the allegation, it was reported that Resident 2's (R2)
clothing was stolen by an employee but the bag of clothes were later returned. LPA conducted a review of facility incident reports for R2, but there is no record of R2's belongings reported being stolen during their stay at the facility. Furthermore, a review of resident file reveal that both R1 and R2 declined to fill out and complete the Client/Resident Personal and Valuables (LIC 621). R2 no longer resides at the facility. R2 moved out with R1 June 2023. Copy of their last service receipt notes that all their belongings were removed on 06/23/23. In addition, LPA conducted interviews with seven (7) of seven residents, who did not express any concerns of their belongings being lost or stolen. Note that the reporting party did indicate that the bag of clothes was later returned. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff stealing R2's belongings. Therefore, the allegation is deemed
Unsubstantiated
at this time.
Staff are not providing adequate food service to residents:
In regards to the allegation, it was reported that
food is inedible and low quality. R1 and R2 could not be interviewed regarding food service as moved out on 06/23/23. Interview with S1, who recalls when both R1 and R2 resided at the facility. According to S1, both residents had their meals delivered to their room. During their stay, both residents expressed no complaints or concerns regarding the food service. LPA conducted a physical plant inspection of the food service during meals, and did not observe food to be of low quality. Furthermore, interviews with seven (7) of seven residents expressed no complaints or concerns of the food service. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff not providing an adequate food service to residents. Therefore, the allegation is deemed
Unsubstantiated
at this time.
