Complaint·May 3, 2024

The investigation revealed the following: Allegation #1 Staff did not seek timely medical attention for a resident. The details of the complaint alleged that the facility did not seek timely medical attention for the resident and that the resident was in severe pain. It was reported that the staff stated the resident was transitioning and only contacted hospice. On 04/04/24, from 10:30am-2:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. R1 could not be interviewed because R1 has moved to another facility and was not cognitively coherent to answer pertinent questions. 3 of 3 staff denied the allegation Staff did not seek timely medical attention for a resident. S1-S3 stated that all residents receive timely medical attention and that every measure is taken to ensure that medical needs are met according to their care plan. Staff further state that when residents are on hospice, they can only call the hospice agency and are only given comfort measures. Staff stated that on 01/03/2023 the hospice agency was notified, and the family was too because R1 was in severe pain. LPA reviewed the SIR (Dated 01/04/2023) submitted by the facility and did not find any discrepancies in the time it took to notify the proper authorities of the residents’ medical issues in a timely manner. LPA further reviewed the hospice plan of care (Dated 12/02/2022) that allowed for a comfort kit (morphine sulfate 20mg/0.25ml) if the resident was in pain. LPA interviewed R1-R4 about the allegation that the Staff did not seek timely medical attention for a resident. 3 of 4 residents that were interviewed stated that when medical attention is needed the facility gives them timely medical attention and that they are satisfied with the care and supervision given by the staff. Based on interviews and records reviewed there is insufficient evidence to support the allegation that Staff did not seek timely medical attention for a 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 . Allegation # 2- Staff did not have accurate records for a resident. The details of the complaint alleged that the facility did not have accurate medication records for the resident in care. On 04/04/24, from 10:30am-2:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. R1 could not be interviewed because R1 has moved to another facility and was not cognitively coherent to answer pertinent questions. 3 of 3 staff denied the allegation that Staff did not have accurate records for a resident. S1-S3 stated that R1s records were up to date. LPA reviewed R1’s Medication Administration Record (Dated October -January 2023), Physicians Report LIC602 (Dated 07/04/2022), Daily Monitoring Record (Dated October 2022 -January 2023), and Hospice Plan of Care (Dated 12/02/2022) and did not find any discrepancies in R1’s record. LPA interviewed R1-R4 about the allegation and 3 of 4 residents that were interviewed denied the allegation that Staff did not have accurate records for a resident. Residents stated that they believe that all records were accurate and that they believed that the facility had up to date records of their medical issues. Report continued on LIC 9099-C Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff did not have accurate records for a 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 . Allegation # 3- Staff did not address a resident's change in medical condition. The details of the complaint alleged that the facility did not address the residents change in condition because the resident was in pain, with family members. On 04/04/24, from 10:30am-2:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. R1 could not be interviewed because R1 has moved to another facility and was not cognitively coherent to answer pertinent questions. 3 of 3 staff denied the allegation that Staff did not address a resident's change in medical condition. All staff stated that any change in a resident’s condition would be immediately addressed with the family, hospice, and the primary physician as it was done in this case. S1 stated that S1 contacted the family member and told them that R1 was not eating well and had a poor appetite, and that the hospice nurse was visiting R1 to monitor R1’s condition. S1 further explained to the family member that R1’s blood pressure and oxygen levels were not in the normal range and that the hospice agency was contacted to oversee R1’ condition. S1 stated that when R1 was in pain the hospice nurse would administer morphine as a comfort measure. LPA reviewed the hospice plan of care (Dated 12/02/2022) and found that skilled nursing visited R1 twice per week and administered PRN, if change in status, as needed. As well as a Home Health Aide that also visited twice per week; the plan entails bathing, dressing, toileting, transferring/ambulation, hydration, grooming, medication administration, and assist and encourage food intake. LPA interviewed R1-R4 about the allegation and 3 of 4 residents that were interviewed denied the allegation that the Staff did not address a resident's change in medical condition. Residents stated that the staff are responsive and inform the family, hospice, or their primary care physician, if changes are detected in their medical condition. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff did not address a resident's change in medical condition. 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- Staff administered unauthorized medications to a resident. The details of the complaint alleged that the facility administered unauthorized morphine medications to the resident while in care. On 04/04/24, from 10:30am-2:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. R1 could not be interviewed because R1 has moved to another facility and was not cognitively coherent to answer pertinent questions. Report continued on LIC9099-C 3 of 3 staff denied the allegation that Staff administered unauthorized medications to a resident. All staff stated that they did not administer any unauthorized medication that was not authorized by hospice. LPA reviewed the hospice plan of care (Dated 12/02/2022) and hospice medication list (Dated 01/02/2023) and found that R1 was prescribed morphine sulfate 20mg/0.25ml as needed, if R1 was in pain. LPA interviewed R1-R4 about the allegation and 3 of 4 residents that were interviewed denied the allegation that the Staff administered unauthorized medications to a resident. Residents stated that they did not have any issues with the staff giving them unauthorized medications from their primary care physicians. They stated that all medications were authorized from their primary care physicians and were satisfied with the care and supervision provided by the staff. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff administered unauthorized medications to a 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 . Allegation # 5- Staff did not provide adequate care and supervision to a resident. The details of the complaint alleged that the facility did not provide adequate supervision and care to the resident because the resident was in pain. On 04/04/24, from 10:30am-2:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. R1 could not be interviewed because R1 has moved to another facility and was not cognitively coherent to answer pertinent questions. 3 of 3 staff denied the allegation that Staff did not provide adequate care and supervision to a resident. S1-S3 stated that the resident received regular medical attention, care, and supervision by the staff, and the hospice agency. There was a hospice care team that came weekly, according to the hospice plan of care (Dated 12/02/2022) and staff that assisted with the residents’ activities of daily living, according to the daily monitoring logs (Dated October 2022-January 2023). LPA reviewed the Physicians Report (Dated 07/04/2022) and the Medication Administration Report (Dated October 2022-January 2023) and found that R1 was getting regular visits from a physician and was getting regular medication. LPA interviewed R1-R4 about the allegation and 3 of 4 residents that were interviewed denied the allegation that the Staff did not provide adequate care and supervision to a resident. 3 of 4 residents stated that they were getting adequate care and supervision from the staff. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff did not provide adequate care and supervision to a 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 Joseph Sol, Licensee, and a copy of this report was provided.