complaint·December 29, 2021

Continued from 9099 During the virtual visit, between the hours from 3:30p.m. to 5p.m., LPA Chochian conducted a virtual physical plant tour with administrator and discussed allegation. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Special Investigator Peter Zertuche. On 08/26/2020, Special Investigator Zertuche conducted an interview with the reporting party at approximately 11:30a.m.; interview with R1’s responsible person at approximately 12:30p.m.; interview with facility staff on 09/17/2020 at approximately 11a.m. and 11:30a.m. and on 9/22/2020 at approximately 9a.m. Additionally, Special Investigator Zertuche, conducted an interview on 09/23/2020 with ABC Hospice visiting nurse. During investigation, Investigator Zertuche obtained and reviewed hospital medical records, hospice records, and R1’s facility records. Information gathered revealed that R1 was admitted to the facility on 05/18/2020. ABC Hospice was initiated the same day due to R1’s declining health status. Staff indicated they regularly repositioned R1 every two (2) hours as instructed by hospice nurse. ABC Hospice agency staff interview stated the focus was on R1 declining health due to Alzheimer’s disease, not wound care as R1 did not have any wounds upon start of hospice care. Throughout the stay at the facility, R1 received hospice service twice a week from 05/18/2020 (start of care) – 06/05/2020 (end of care). Hospice records indicate R1 received care services from hospice staff on 05/18/2020; 05/20/2020; 05/21/2020; 05/24/2020; 05/27/2020; 05/30/2020; 06/01/2020; 06/03/2020; and 06/04/2020. Hospice records indicate, wounds did not form until 6/1/2020 – a blister/redness on coccyx area observed on 06/01/2020 and a deep tissue injury to the right foot/heel on 06/03/2020. Facility staff were instructed to continue monitoring R1 and reposition every 2 hours. Hospice notes further reviewed revealed that R1’s family was regularly kept informed by visiting hospice staff of R1’s declining health condition and on 06/05/2020 family decided to have R1 transfer to the hospital. According to hospice staff there was no concerns regarding the care provided by the facility staff took immediate action when they found out about the injuries. Continued from 9099-C Regarding allegation “Facility staff could not provide resident's authorized representative with the resident's medical information”, it was reported that when R1’s family asked staff about what medications R1 is on and staff did not know. Interview was conducted with facility staff during the initial visit on 06/11/2020 by Licensing Program Analyst Zabel Chochian. Interview with staff revealed that the staff that was asked about R1’s medications at the time did not know because they do not handle medications. Regarding allegation “Facility staff did not notify resident's authorized representative of a change in the resident's condition”. It was reported that the facility did not advise R1’s family that the resident was declining or that the resident's mental status became altered. Interview with facility staff and hospice staff revealed that R1’s family was regularly informed of R1’s declining health status. Several attempts were made to contact R1’s family on 6/11/2020; 08/31/2020 and 09/15/2020; no return call was received. Based on the above information, there is not enough evidence to support the allegations. Therefore, the allegations are deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided.