complaint·January 24, 2024

The Department received a statement from the complainant indicating that the facility did not follow hospice orders. Sutter Health Hospice ordered the facility to not feed R1 due to R1’s body shutting down. R1 was in hospice and had refused to eat when offered food or when asked if R1 was hungry. Food is to be provided when R1 requests it. On 07/18/2023 at 8 PM, R1’s responsible party (RP) called the facility to check on R1 and was notified that staff (S1) was able to get R1 to eat a bowl and a half of pureed food. Complainant and RP believed, R1 was forced fed by S1. R1 refused to eat when offered food or when asked if R1 was hungry for four (4) days. On 08/01/2023, R1 was relocated to another residential care facility for the elderly. On 08/05/2023, R1 passed away due to declining. The Department requested and reviewed R1’s physician’s report. The physician’s report indicated that R1 is on a special diet and R1 can feed self. R1’s preplacement appraisal information indicates that R1 has Diabetes Type 1 and 2. R1 is on a diabetic diet and requires finger stick sugar checks. R1 is diagnosed with Dementia. The Department received an interview statement from R1’s RP. RP stated that the facility did not follow hospice’s orders to stop feeding R1. There was no written order from R1’s physician or hospice. The direction was given verbally by hospice which the facility failed to follow. The Department interviewed a total of three (3) facility staff. Interview statement received from S1 indicated that R1 can communicate needs and often request for something to drink. S1 denies force feeding R1. S1 stated residents have the right to refuse and if they don’t want to eat the staff would not force them. Same goes for medications. Interview statement received from S2 indicated that R1 was on a special diet. The hospice nurse conducted visits to the facility to check on R1 and notified staff if R1 was hungry to provide food to R1. S2 stated hospice never notified the facility to stop feeding R1. S2 stated if staff do not feed R1 when R1’s hungry or when R1 request for food then that is considered neglect. Interview statement received from administrators indicated there were no doctor’s orders to stop feeding R1. On 11/14/2023, the Department called and spoke to R1’s Sutter Health Hospice Nurse. The Hospice Nurse refused to provide a statement and requested the Department to reach out to Sutter Health Hospice management to get approval. Hospice Nurse explained Nurse is not allowed to provide any information until management approves of it and this is due to company’s policy. The Department reached out to Sutter Health Hospice Manager and requested for an approval. Sutter Health Hospice Manager stated will reach out to CCL once there is direction on how to proceed with getting authorization. The Department did not hear back from Sutter Health Hospice. On 01/11/2023, the Department reached out to Sutter Health Hospice and spoke to another Sutter Hospice Manager. The Department requested an update on the authorization. Sutter Hospice Manager stated will get back to CCL and will have to ask management for approval. The Department was unable to gather statements from R1’s hospice nurse. Due to the information above, CCL finds the allegation to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was left at the facility.