complaint·April 26, 2024

The investigation revealed the following: Regarding the allegations that Resident sustained pressure injury while in care and Staff did not seek medical assistance for resident in a timely manner. It was alleged that before R1 death R1 had “gurgling noises”, had a vaginal bleeding and was in severe pain many times and facility staff never called a doctor for pain,bleeding or for aspiration. Also, it was indicated that R1 developed a sore on her foot. R2 had a low blood pressure and staff said that they not going to call 911 and were not going to give blood pressure medication. Interviewed Administrator and Assistant administrator denied the allegation. They stated that both residents were under the same hospice care: “Comfort Hospice Care”, and they were instructed to call hospice 24/7 for any reports/significant changes, which they did. Hospice nurse visited residents twice a week and staff always contact / report to the hospice when they noticed any significant changes on R1 and R2. LPA obtained and reviewed Hospice notes for R1 and R2. For R2 it said that at the time of nurse visits on 2/1/2019 ”vital signs are low but are still within normal parameters including blood pressure”. R2’s daughter requested doctor’s visit and the visit scheduled at the next day. Hospice MD was notified and obtained new order for R2. Administrator stated that R1 was incontinent and when staff changed the resident, they never noticed that R1 was bleeding. Review of hospice agency documentation shows that R1 never had vaginal bleeding. Hospice documents showed that R1 started continuous care (round a clock nursing supervision) from 5/28/2019 – 5/30/2019 because of R1’s last stage of their life. Patients/residents declining and last stage of their life they always have moaning and gurgling noises. The gurgling noise is due to patient unable to swallow their saliva. R1 admitted under Comfort Hospice Care as of 04/08/2019. Per Register Nurse's Initial evaluation and head to toe assessment patient did not have any wounds but had very sensitive skin and on high risk for open wounds. R1 transferred to facility with DTI (Deep Tissue Injury) which is very common for patients with CVA (cerebral vascular accident) diagnosis. Patient never had a pressure ulcer not in the hospital (from R1 was transfered to the facility), not at the facility. On 05/24/2019 report from visiting nurse said that R1’s Left Foot Deep tissue injury has opened and is now a Stage II Left foot pressure ulcer, which is very common with bed bound patients /residents. Wound has been treated appropriately and reported to doctor. For the pain R1 was prescribed Tylenol, Tramadol and at the letter time Morphine for lot of pain by the Hospice Doctor. Continue 9099C Regarding the allegations that Resident choked while in care and Staff handled resident in a rough manner. It was alleged that staff very rough with R1 specifically S3 and staff would aggressively feed R1 which caused resident to choke. During interviews, Administrator and Assistant Administrator stated that staff have never handled residents in a rough manner. They have never witnessed that staff handle residents in a rough manner. They stated that staff treat residents with dignity and respect. Administrator has never received any complaints from residents and staff that S3 has handled R1 in a rough manner or aggressively feed R1 which caused resident to choke. Interviewed Administrator and Assistant Administrator indicated if residents could feed themselves, staff would let residents eat at their regular time and will never force them. Staff will help / assist residents if it’s necessary. LPA observed on the hospice notes says that assistance needed for R1 with feeding. At the lunch time, during the visit LPA didn’t observe that staff force feeding residents. During the visit, LPA was informed that S3 is no longer employed at the facility. LPA was unable to contact S3 for an interview. Regarding the allegations that Staff mismanaged resident's medication and Staff administered unprescribed medication. It was alleged that facility staff overmedicating R2, and facility administrator and assistant administrator were adjusting the medications dosage without doctor’s order: giving Ativan without doctor’s order and increasing dosage of medication at night. R1 was always sleepy, and staff inform family member that R1 was really loud, so they give R1 something to make R1 sleep. Interviewed Administrator and Assistant Administrator denied the allegations. They stated that medications from hospice always coming in bubble pack and medication dispensed in the facility are under Dr. orders, they never dispense,they never hold or provide any extra medications without Dr. orders. R1 and R2 got their medications timely and as prescribed. LPA obtained and reviewed Hospice notes for R1 and R2. R1 was under hospice care since 04/08/2019. LPA noticed that for R1 there was a doctor’s order for the medications; Xanax 0.25mg/ daily, Xanax 0.25mg/daily at bedtime as needed for agitation/anxiety, Restoril 15mg/daily, Melatonin 10mg/ daily, Seroquel 25mg/twice daily for agitation/anxiety and insomnia. Hospice notes said under the influence of those medications’ patient/resident sleep during the day. R2 was under hospice care since 12/15/2018. For R2 was doctors order for Ativan/Lorazepam 2mg daily every 4 hours as needed for agitation/restlessness, Seroquel 100mg, Trazodone 100mg daily for Insomnia. On 02/08/2019 per R2 family member/ granddaughter those medications were discontinued by the Hospice doctor. There was new doctor’s order for R2, Start Ativan /Lorazepam 1mg/1 tab by mouth daily at bedtime as needed for agitation/insomnia. Facility staff and family were informed about changes. Continue 9099C Regarding the allegation: Illegal eviction. It was alleged that R2 will be evicted due to the R2’s granddaughter interference and administrator offered to transfer resident to another facility. Administrator and Assistant administrator denied the allegation. They stated that there was never any eviction notice issued to R2, even though R2 had several moments of aggression towards the caregivers and other residents. R2 would punch, scream, and would throw anything that she could grab on. That was family decision to move R2 from the facility. On 02/10/19 R2 relocated to R2’s daughter home, under the hospice care. Regarding the allegation: Staff restrained resident. It was alleged that R1 had a gait belt on her wheelchair and R1 was dressed over the gait belt which was against R1 skin. R2’s daughter came to visit and found armchair furniture all around R2’s bed. Administrator and Assistant Administrator denied the allegation. The use of restrain were never use with any of the residents. In or out of the bed. They never used armchairs around of resident’s bed to restrained them. Administrator stated that R1 had a gait belt on their wheelchair to prevent falls not for restraint resident. During the record review LPA observed the gait belt that R1 used was prescribed by the doctor for resident safety and fall prevention. On Hospice notes were nothing indicated about R1's skin damaged / injury /wounds because of gain belt against the skin. Administrator also indicated R1’s family members were acknowledged the gait belt.The gait belt used around the wheelchair for safety issues. Continue 9099C Regarding the allegation: Staff did not safely use resident's wheelchair. was alleged that facility would not always put foot pedals on the wheelchair and caregivers would “pop wheelies” in order to maneuver resident. Interviewed Administrator and Assistant Administrator denied the allegation. Wheelchair pedals are always attached to resident wheelchair, unless PT (Physical Therapist) moves and walk around and to prevent injury we removed, but we notified the doctor. Administrator and assistant administrator never witnessed that caregivers “pop wheelies” to maneuver resident. Facility staff very careful when they are assisting residents on the wheelchair. At the time of visit LPA observed residents on the wheelchair in the living room. All wheelchairs have a foot pedals and caregivers handled residents very carefully. Based on statements and interviews conducted, review of residents files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held with Administrator Humberto Santamaria and a copy of this report was provided.