complaint·February 1, 2024

The investigation revealed the following: Regarding allegation: Staff leave resident in bed for prolonged periods of time. It is alleged that R1 reported to have been left in bed for 3 weeks and had not been outside. Per interviews conducted with staff, (5) of (5) staff denied the allegation and stated R1 required a (2) to (4) person assist when transferring, but was not willing to cooperate with staff during the transfers and would throw self back during the assists, making it more difficult to transfer. Staff stated they had no issues with transferring other residents that required the assistance. Per resident interviews, (4) of (5) residents could not corroborate the allegation. After review of R1's Care Plan, it was noted that R1 requires a (2) to (4) person assist to transfer. Per R1's Physician's Report, R1 is non-ambulatory and is unable to transfer out of bed on their own. R1's Appraisal/Needs and Services Plan indicates R1 requires maximum assistance with mobility and transferring in and out of bed/chair. Per Hospice Notes and facility Progress Notes, it was discovered that on 2/05/23, R1 was assisted by facility staff with standing. On 2/10/23, R1 was assisted by (2) facility staff with transferring to chair, but was throwing self back even while being assisted. On 2/22/23, R1 refused to be assisted by facility staff with care. On 03/02/23, assistance with transfer was provided by (3) staff, and R1's guardian was later notified of R1's refusal to care despite being provided with a (2) person assist. On 4/25/23, while R1 was moving out of the facility, R1 had a (4) person assist, and although R1 was able to get up, R1 then refused to be assisted into the car that was picking R1 up. Per interview conducted with R1's hospice agency, and per hospice record review, there was no written order for use of a hoyer lift to assist with R1's transfers, although the hospice care physician only made a verbal recommendation that a hoyer lift could help. The facility is not required to have a hoyer lift, and per interview with Administrator, none of the facility staff are trained to use a hoyer lift due to the facility not using or owning one. There are no residents in the facility who require assistance with transfer by hoyer lift. 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. An exit interview was conducted and a copy of this report was provided.