complaint·March 28, 2025

LPA conducted (2) staff interviews with staff who cared for R1. (2) of (2) staff revealed R1 was bedridden and unable to turn or reposition themselves in bed, and was turned every (2) hours. They revealed staff made attempts to get R1 out of bed but R1 was unable to tolerate it. (1) of (2) staff revealed a Hoyer lift was not used on R1 as R1 would yell out in pain due to a sore on their body. Admission agreement and Hospice visit notes for R1 revealed R1 resided at the facility from 11/21/2022 to 12/24/2022. R1’s Hospice Care Plan from 11/21/2022 revealed R1 had a pressure injury on their bottom and was bedbound. Hospice equipment list revealed a Hoyer lift was ordered 10/31/2022, prior to R1 being placed at the facility when they were deemed non-ambulatory. The facility’s internal “Two-hour Turn Log to Prevent Skin Breakdown” was documented every (2) hours for the resident during R1 stay at the facility. Therefore, the allegation that R1 was not provided with the opportunity to be out of bed is unsubstantiated at this time. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided. Staff interview revealed R1 arrived at the facility with (2) medication patches on their body from their previous placement. It was revealed R1’s legal representative and a representative from R1’s hospice agency were also present for the incident. Interview with R1’s legal representative confirmed they witnessed R1 arrive to the facility with (2) medication patches on their body. R1’s medication’s list revealed one medication patch for M1 was prescribed every 72 hours. Hospice visit notes for R1 revealed they resided at the facility from 11/21/2022 to 12/24/2022. The visit notes did not reveal any medication errors for R1’s patch. Therefore, the allegation that staff did not administer R1’s medication patches as prescribed is unfounded at this time. It was alleged “Staff do not follow physician's order”. It was alleged R1’s speech pathologist ordered to not thicken R1’s liquids and that facility staff did not comply. Additional information for the speech pathologist was not available and review of R1’s hospice care plan did not reveal an assigned speech pathologist. Interview with R1 was unable to be conducted as R1 has since passed away. LPA conducted (2) interviews with staff who cared for R1. (1) of (2) staff did not recall a speech pathologist being assigned to R1, and they recalled having physician’s orders to thicken R1 liquids as R1 had difficulty swallowing. Medications list for R1 revealed fluid thickener was ordered by R1’s physician and started on 10/5/2022. Instructions on the medication list stated to thicken liquids to a nectar thick consistency. Therefore, the allegation that staff were not following R1’s physician orders is unfounded. This agency has investigated the complaints and have found that the complaints are unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.