complaint·April 5, 2023

According to the hospice nurse report, “the facility staff is non-compliant with the current order and occasionally skipping medication for pain or anxiety, they state are providing when patient ask”. The hospice nurse’s report further stated that the nurse educated facility staff on the need for medication compliance. Allegation # 2 “Staff did not inform resident's authorized person of incidents”. The allegation alleged that facility staff did not provide incident reports to the family or hospice. The allegation alleged that out of four (4) incidents, they received only two (2) reports from the facility. LPA Interview with the Licensee revealed that the administrator would notify the hospice company because the hospice company determines if the client needs to go to the hospital. The Licensee stated that the hospice company would notify the family, and the hospice company would send out a nurse to access the client. The Licensee stated that the administrator would send an incident report to licensing. LPA interview with the RP revealed that the facility never notified them about incidents surrounding R1. RP stated that they learned about R1’s incidents from R1. LPA file review revealed that on November 16, 2021, a hospice nurse visited the facility because R1’s authorized representative called the hospice company reporting that R1 contacted their authorized representative to report they fell. LPA file review also revealed that the facility did not notify our agency. Based on the evidence gathered during the investigation, the above allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met. An exit interview was conduct were a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provide. LPA interview with the RP revealed that the RP picked up R1 on two (2) occasions, and the facility provided the RP with two empty oxygen cylinders for R1. RP stated the first incident, they went back and found a full oxygen cylinder the second incident, they did not. RP stated the second incident I had to take R1 to the dentist, and the facility had no oxygen cylinder for R1; therefore, the facility provides an electric portable oxygen machine. RP stated that R1 only had access to their oxygen once they arrived at the dentist's office and had access to an electrical outlet to plug up the portable oxygen machine. RP stated that when they addressed this issue with the Licensee or the administrator about the facility not having oxygen cylinders for use outside the facility. RP stated that the Licensee or Administrator would always blame the oxygen delivery service for the facility's ability to retain the oxygen cylinder for R1. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #2 “Staff improperly stored resident's medication”. The allegation alleged the R1’s medication was stored in the refrigerator with other food. LPA interview with the Licensee revealed that medication requiring refrigeration is stored in the back refrigerator. LPA interview with the RP revealed that they observed the medication on the side of the refrigerator where the butter is stored. LPA observed revealed that is storing medication in the refrigerator in a safe manner, the medication was stored in the refrigerator in lock boxes. LPA cannot attest to how the facility stored medication when this allegation was made; therefore, the finding is unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation # 3 “Facility not kept clean”. The allegation alleged that the facility toilet was dirty for extended periods. LPA interview with the Licensee revealed that the facility is cleaned throughout the day. The Licensee stated that the facility’s detailed cleaning occurs when the clients are in bed. LPA interview with the RP revealed that the facility commode was full of feces for extended periods. LPA observed that the facility was clean and did not observe any dirty toilets. LPA cannot attest whether the facility was not kept clean when this allegation was made; therefore, the finding is unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #4: “Resident sustained a fall while in care”. The allegation alleged that R1 slipped in her urine. LPA interview with the Licensee revealed that the facility staff would check if a client had an accident and the floor was wet. LPA interview with the RP revealed that R1 slipped in her urine in her bedroom; however, the RP did not know if R1 urinated trying to make it to their commode or slipped on urine on the floor that the facility failed to clean up. The finding is unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #5 “Resident was slapped by another resident” The allegation alleged that R1 was slapped by resident #2 (R2). The allegation also alleged that a member of the facility staff advised RP that they were attempting to get R2’s medication adjusted. LPA interview with the RP revealed that R1 informed the RP that R2 slapped R1 on the leg as they were trying to walk by. The RP stated that they spoke with the Licensee about the incident and the Licensee. RP stated that they were trying to get R2’s physician to adjust their medication. The RP also stated that they were unaware of any issues between R1 and R2. LPA interview with the Licensee revealed that although the Licensee was not present when the incident occurred, their staff notified the Licensee about the incident. The Licensee stated that R1 and R2 did not get along. The Licensee stated that R1 and R2 were not roommates and did not enter each other’s rooms. The Licensee stated that R1 and R2 only saw each other in the facility's common areas, and the facility was doing all it could to separate the two (2) residents. A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and copy of this report was provided.