complaint·October 10, 2024

Allegation: Facility staff are not making arrangements to meet residents' health needs. It was reported that resident (R1's) primary care physician informed staff that the resident's healthcare plan was contacted requesting a Cardiologist and Pulmonologist consult, but the facility did not follow through because staff stated that they do not provide transportation to medical appointments. Based on record review, resident (R1) has had a decline in health during the past year, and was hospitalized from June 21, 2024 - June 24, 2024 and placed on home health upon return to the facility. The resident had been enrolled in home health services earlier in the year. Per record review, on July 9, 2024, there was communication between Wellness Director and R1's Medical Doctor, in which MD informed staff that a Cardiologist and Pulmonologist consult referral was sent to R1's insurance provider, as well as a transportation referral. Three staff were interviewed, they confirmed the facility got verbal notification from Medical Doctor that R1 required a Cardiologist and Pulmonologist consult, but stated that they did not receive written referral information for the specialists. Facility charting notes confirm that R1's Doctor informed staff. Resident (R1's) family member was interviewed. They confirmed R1 has not been seen by specialist doctors and was not notified by facility staff that the primary care physician made the facility aware of the referrals on July 9, 2024. Therefore, the residents health needs are not being met. Allegation: Facility staff are not ensuring that residents are receiving an annual medical assessment as required. According to information obtained on June 13, 2024, facility med-tech staff contacted resident (R1's) primary care physician requesting medication refills for 4 medications. However, R1's physician informed staff that the resident has not been seen at the doctor's office in over 2 years. Therefore, the medications would not be refilled. Records indicate the resident moved in 12/12/2022, and upon move-in a Physician's Report dated 12/6/2022 was obtained. A total of 7 residents were interviewed, none reported issues pertaining to the allegation. Based on record review, resident (R1) has mild cognitive impairment and no Dementia. However, record review and staff interviews revealed that resident (R1) was sent out to urgent care in December 2023. A change in condition was noted. On 2/21/2024, the resident was enrolled in home health services, and was sent out to the hospital in early March 2024. In May 2024, staff observed physical changes in need of medical attention. On June 21, 2024, R1 was sent out to the hospital and returned on June 24, 2024, with physical therapy physician order. On July 22, 2024, R1 was enrolled in hospice care. Staff acknowledged R1 had changes in condition since early January 2024, but did not the contact the resident's primary care physician to schedule an annual medical exam. LPA conducted a visit on 7/25/2024 and collected R1's Physician's Report dated 12/6/2022. After that visit, staff obtained an updated Physician's Report dated (7/29/2024) from hospice MD, which indicates the resident has heart failure and requires total care. Staff observed deterioration of physical health condition for months but did not bring to the attention of R1's physician. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED . Deficiencies are being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.