Complaint·January 17, 2023

Interviews and review of hospice care notes revealed that during a hospice care visit, hospice staff observed small bruises on R1’s left jaw and back in September 2021, and healing bruises on R1’s left eye and left jaw, and a small bruise on R1’s left forearm in October 2021. Interviews revealed that facility staff were not aware of the bruises observed in September 2021, and denied hitting or causing R1’s bruising. Interviews and hospice care notes revealed that a care conference was conducted to discuss R1’s bruising between facility staff, the Licensee, R1’s family, and hospice staff in October 2021. Interviews revealed that R1’s family stated that R1 could have obtained the bruises by moving around in the bed and hitting the bed rails. The Licensee stated that R1’s sedative medication was not working and R1 was banging their head against the bed rails. Interviews revealed that facility staff were not administering R1’s sedative medications as prescribed due to concerns that R1 would be overly sedated. Hospice staff provided staff with education regarding administering medication as prescribed and padding was placed over the bed rails to prevent further bruising during the care conference in October 2021. Interviews with outside sources did not reveal any concerns regarding R1’s care. Interviews with skilled medical professionals revealed that bruising was possible after an episode of agitation and hitting against the bed rails. Review of hospice care notes revealed that no new bruising was observed after October 2021. The Department was unable to interview R1 due to R1 passing away. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Caregiver Mila Caganap, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.