complaint·August 24, 2023

Regarding Allegation #1 : Licensee neglect resulted in resident sustaining hip fracture. This complainant alleges resident fell sustaining a hip fracture. On 07/24/2023 LPA Calderon reviewed the Department of Social Services Investigation Branch (IB) investigator Hector Santiago report. The investigators report expresses on 04/28/2023: Interviews were conducted with outside sources, administrator, and staff. An attempted interview was made with R1: however, due to her neurocognitive disorder, I was unable to obtain any pertinent information. R1 facility and medical records were also reviewed. On 03/02/2023 R1 was admitted to the facility and was assessed as a “fall risk”. R1 was placed in a “heavy care unit” where R1 was frequently supervised every 15 to 30 minutes instead of the standard bihourly protocol. R1 physicians report revealed that R1 was no ambulatory but can independently transfer to and from bed was able to communicate needs and was not considered a “wanderer.” A review of medical records revealed that R1 was diagnosed with history of severe osteoarthritis and osteopenia as well as swollen lower extremities. In addition, R1 was diagnosed with a history of hip and groin pain prior to being admitted to the facility. Interviews with staff and R1 family member corroborated the R1 did not have any reported falls or complaints of pain on 03/02/23 and 03/03/23. On 03/04/23, R1 was observed to be agitated and was found to be sliding off the bed where R1 was found on the floor several times. However, each time the caregivers assisted the R1 back to bed, R1 did not indicate R1 was severely hurt and sometimes refused care. During R1 last fall in the evening, two caregivers assisted R1 to R1 wheelchair and propped R1 feet up to keep R1 from sliding off the bed. R1 family member later attempted to lower their leg and that was when R1 expressed excruciating pain. Emergency medical services was initiated, and R1 was taken to the hospital where R1 was diagnosed with a hairline fracture of the pelvic bone. Staff denied that they saw R1 appear in pain or in distress prior, they also denied that the R1 was dropped during transfers. Based on the evidence gathered from investigation, there is insufficient evidence to prove that the facility failed to provide adequate care that resulted in R1 sustaining a hip fracture. Therefore, the allegation is unsubstantiated. Regarding Allegation #2 : Facility staff did not ensure resident had prescribed medication. This complaint alleges that staff did not order residents prescribed medications. On 07/10/2023 LPA Calderon interviewed A1 who expressed that R1 moved into the facility on 03/02/2023 and moved out on 03/04/2023. A1 expressed that the facility doctor examined R1 on 03/03/2023 and medications were ordered per the doctors’ instructions. A1 expressed that R1 never ran out of R1 medications prior to leaving the facility on 03/04/2023. On 07/10/2023 LPA Calderon interviewed S1-S3 who expressed that R1 moved into the facility on 03/02/2023 and was living in the facility for less than one week. S1 expressed that the facility doctor changed R1 medications for R1 due to health issues. S1 expressed that R1 never ran out of medications while staying at the facility. On 07/10/2023 LPA Calderon could not interview R1 for complaint as R1 moved out of the facility and had health issues. On 07/10/2023 LPA Calderon interviewed R2-R12 for complaint. R2, R4 expressed that staff are always behind in time when staff provides residents medication. R2, R4 express that staff does provide medications to residents daily. R7, R11 expressed that they self-medicate and keep their medication in their rooms. 11 out of 11 residents expressed that staff ensures that residents prescribed medications are ordered and residents never run out of resident’s medications. On 07/24/2023 LPA Calderon reviewed MAR for March 2023 for R1, no errors found, and staff did not miss giving medication to R1. On 07/24/2023 LPA Calderon reviewed the Medical Discharge Report (03/01/2023), Physician Orders (03/03/2023) and Proof of Prescription Delivery (6) ordered on (03/03/2023) which support the facility had ordered R1 prescriptions for R1 use. Regarding Allegation #3 : Facility staff changed residents’ medication without authorization. This complaint alleges staff changed medications for resident use without authorization from R1 family. On 07/10/2023 LPA Calderon interviewed A1 who expressed that R1 moved into the facility on 03/02/2023 to 03/04/2023 when R1 family moved R1 out of the facility. A1 expressed that the facility doctor examined R1 and ordered a prescription change for R1 health issues on 03/03/2023. A1 expressed that no change was made without authorization from R1 family. A1 expressed that A1 communicated daily with R1 family and informed R1 family of any medication changes that were done. On 07/10/2023 LPA Calderon attempted to interview R1 for complaint, but R1 no longer lives at facility. On 07/10/2023 LPA Calderon interviewed S1-S3 for complaint. S1-S3 expressed that any change to R1 medication list was authorized by R1 family. S1-S3 expressed that staff do not speak to R1 families directly and S1-S3 would advise A1 of changes which would be passed along to R1 family. On 07/10/2023 LPA Calderon interviewed R2-R12 for complaint. 11 out of 11 residents expressed that A1 does communicate with residents and their families regarding any medication changes. R7, R11 expressed that they self-medicate, and staff makes sure to inform them of any medication changes. On 07/24/2023 LPA Calderon reviewed medication prescription and physician orders for R1 (03/03/2023). Records suggest that R1 medications were ordered on 03/01/2023 and 03/03/2023. On 07/24/2023 LPA Calderon reviewed Proof of Prescription Delivery (6) ordered on 03/03/2023, LPA Calderon noted that “patient was counseled”. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of “licensee neglect resulted in resident sustaining hip fracture” “facility staff did not ensure resident had prescribed medication” “facility staff changed residents’ medication without authorization” is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to the Administrator Peggy Clark (A1).