complaint·September 12, 2023

Continued From LIC9099. Regrading the allegation “Facility violated Resident personal rights: Resident was found only in diapers with no clothing”, It was alleged on 01/19/2022 staff left resident in diapers. Staff was interviewed who denied having resident only in diapers. Staff reported resident is always dressed. Staff stated on 01/19/2022 resident was swinging and hitting staff, knocked food out of staff hand while staff was trying to feed resident. Resident’s Responsible party (RP) was interviewed, interview revealed resident was always dressed except on 01/19/2022 when resident was swinging and hitting staff. Unsubstantiated. Regarding the allegation “Staff neglect resulted in resident being dehydrated”, Staff was interviewed who stated that resident meal consumption decreased. Staff stated resident was eating about 50 to 60% of the meal. Staff denied knowing resident was diagnosed with dehydration. Hospice medical records were reviewed and showed resident’s appetite and hydration was poor. Resident was on a puree diet and only ate one meal a day. Medical records review showed that resident was admitted to the hospital on 01/24/2022 with dehydration that caused Hypernatremia. Resident’s primary care physician was interviewed who reported reviewed resident’s medical records and it’s impossible to determine if neglect led to resident’s dehydration or due to medical reasons already mentioned in the medical record. Unsubstantiated. Regarding the allegation “Staff are overmedicating resident” staff was interviewed who denied was overmedicating resident. Staff stated resident’s medications were administered to resident according to doctor’s orders. Holistic Care Hospice Manager was interviewed who reported during hospice visits, resident was not observed to be over medicated. Unsubstantiated. Based on interviews with Staff, resident, Resident’s Responsible party, resident's primary care physician and Holistic Care Hospice Manager and resident file review, there is not enough evidence to support the above 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 at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to Tyla Kincherlow.