complaint·September 16, 2022

Per facility records, on 7/16/2020, at approximately 8:38 PM, staff noticed blood in R1’s urine. When asked, R1 denied pain or discomfort. Facility staff assessed R1 finding R1’s vitals normal. Staff notified R1’s primary care physician (PCP), requesting a urinalysis (UA). Staff made several attempts to collect urine samples (per PCP orders) but R1 was uncooperative. R1 was stable from 7/16/2020 to 07/17/2020 and therefore, not transferred to the hospital. R1 was placed on alert charting and monitoring during this time. On 7/18/2020, at approximately 4:15 AM, R1 had an episode of loose bowel movement on their bedroom floor. R1 complained of lower abdomen pain. Facility staff activated emergency medical response via 911. R1 was transported to the hospital Emergency Room (ER). Medical records showed that on 07/18/2020 at about 5:00 AM, R1 arrived at the hospital by ambulance. The primary medical complaint indicated rectal bleeding. During early rounds, hospital staff found R1 with red loose bowel movements and they activated medics. An IV was placed. At about 7:45 AM, staff checked R1 who appeared to be sleeping. Shortly later, staff went to check R1 as the monitor was disconnected. R1 was found lying on the floor unresponsive and no pulse. Due to R1’s Do Not Resuscitate/Do Not Intubate (DNR/DNI) status, R1 passed away at the hospital under medical care. R1`s death certificate disclosed the immediate cause of death as Non-St Segment Elevational Myocardial Infarction; Acute Hypotension; Pneumonia and Probable Gastrointestinal Bleed Cause Unknown. Other significant conditions contributing to R1’s death but not resulting in the underlying cause given; Alzheimer’s dementia with behavioral disturbance, diabetes mellitus type 2; chronic kidney disease stage 2. Interviews and record reviews did not reveal a lapse or delay in staff’s response to R1’s medical condition. Interviews with R1’s responsible persons (RP) stated that R1 was deteriorating quickly. RP said they were notified by staff that blood was found in R1’s waste. RP was informed that staff contacted R1’s physician about the blood and the fact that they were having difficulties obtaining urine samples. Interviews with outside sources, did not reveal evidence of neglect. When asked if staff could have done anything differently in their response to R1’s medical condition, outside sources said, “No.” Outside source interviews did not expose any concerns or complaints with staff response to R1’s medical condition. Due to a lack of supporting evidence, the finding regarding the allegation that neglect resulted in the questionable death of Resident 1 is Unsubstantiated. This finding means that although the allegation may have occurred or could be valid, there is not a preponderance of evidence to prove the alleged violation occurred. An exit interview was conducted with Director Byrne and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) were provided and Director Byrne's signature on this form confirms receipt of these reports.