complaint·December 18, 2024

Allegation: Staff failed to seek medical attention for a UTI and dehydration. Substantiated Staff reported R1 had changes in condition beginning in November 2023. They observed R1’s urine was dark in color and had an odor consistent with a urinary tract infection (UTI). Medical records show R1 was seen at the emergency room on 11/17/2023 for a chief complaint of lethargy. However, medical records show not show a urinalysis test was conducted or that they were ever treated for a UTI. Medical records from this visit show R1 was assessed for behavioral issues and their medications were adjusted. On 12/18/2023, staff began noticing a decline in R1’s condition which included changes in weakness and mobility. Staff contacted R1’s family recommending R1 be places on hospice care. The file review records indicate R1’s primary care physician was not contacted regarding R1’s signs of weakness until 12/24/2023. On 12/24/2023, a fax correspondence was sent to R1’s primary care physician indicating R1 was lethargic, sedentary, and no longer able to feed themselves. The physician did not acknowledge receipt of the correspondence. Multiple staff considered R1’s changes in condition to be drastic and warranted her being sent out to the hospital on 12/24/2023. Staff reported R1 was sent out to the hospital on 12/24/2023. However, medical records support R1 was not sent out to the hospital until 12/25/2023 at approximately 1600 hours. As a result of this investigation, LPA finds the allegation to be Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted. A copy of this report was left with the facility. Allegation: Neglect resulted in resident's death. Unsubstantiated On 12/25/2023, R1 was admitted to the hospital after exhibiting signs of shortness of breath and being unresponsive. R1 was discharged from the hospital on 12/28/2023 and returned to Summerset with a diagnosis of severe sepsis with acute organ dysfunction and urinary tract infraction (UTI). R1 was placed on hospice care on 12/28/2023 and passed away on 1/9/2024. R1’s death certificate lists cause of death as cardiac arrest and pneumonia. Other significant conditions contributing to their death were pulmonary embolism and severe dementia. Based on the information obtained, there is insufficient evidence that facility staff neglected R1 resulting in R1’s death. Allegation: Resident developed a UTI and became dehydrated due to inadequate care by staff. Unsubstantiated R1’s medical records documented that whenR1 arrived at the hospital on 12/25/2023 , they tested positive for a urinary tract infection (UTI) and had signs of dehydration. Staff reported R1 consistently received assistance with toileting and brief changes in a timely manner. Staff also reported R1 consumed and appropriate amount of liquids and did not show any signs of dehydration. It is unclear if R1 had a history of sustaining frequent UTIs and required special measures. Interviews with residents documented staff meet resident’s needs. Based on the information provided, although R1 was diagnosed with a UTI and dehydration, there is insufficient information that staff provided inadequate care. Allegation: Staff did not ensure that resident's room was sanitary. Unsubstantiated Staff interviews revealed that R1 would often have a bowel movement not in the bathroom. Interviews detailed how R1 would the try to hide the BM. Notes detail R1 having a bowel movement on the wall and then screaming at staff when being redirected. Staff stated that R1’s room was generally clean and well kept. Staff interviews also acknowledged that R1 would frequently take all the clothes out of their closet and drawers, causing staff to have to frequently have organize and put the room back together. Based on the information provided, there is insufficient information that staff did not ensure resident’s room was kept sanitary. Allegations: Staff do not provide services to resident as promised. Staff did not ensure that resident's hygiene needs were met while in care. Unsubstantiated LPA interviewed staff regarding the allegations. Interviews stated that R1 was, at time, combative and resistant to care. Staff stated that they would ask R1 multiple times to assist with showering and would try a change of face. LPA reviewed resident notes which detail R1’s combative behavior to care including: ‘attacking’ hospice shower aid and becoming combative with staff. LPA reviewed doctor orders which show an increase in R1’s medications to assist with behaviors. Based on the information provided, staff were documenting when staff were unable to meet R1’s needs. Allegation: Staff handled resident in a rough manner, causing injury to resident. Unsubstantiated LPA reviewed resident notes which detail ongoing combative and aggressive behavior by R1. R1 had a history of being aggressive with staff and other residents. Additionally, notes detail R1 ‘not letting go’ of another resident, grabbing resident’s hair from the back of their head, and screaming. LPA did not identify any incident which R1 had a skin tear due to staff. LPA did not review any documentation regarding R1 having a skin tear or doctor notification of a skin tear. Additionally, facility did not submit an incident report or SOC341 to the department regarding a skin tear R1 sustained caused by staff. Staff interviews indicated that staff did not observe a skin tear on R1. Based on this information, these allegations are UNSUBSTANTIATED . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. Exit interview conducted. A copy of this report was left with the facility .