complaint·July 7, 2021

The Department received a complaint on December 27, 2019 alleging that facility staff failed to seek medical care for resident, staff failed to treat resident(s) with dignity, staff failed to provide incontinence care to resident(s) and that Licensee failed to meet the needs of resident(s). The Department’s review of facility records revealed that resident #1 (R1) and resident #2 (R2)(See Confidential Names List – LIC 811) were residents at the facility in 2019. R1 ambulated using a wheelchair, was on hospice care and needed assistance with some activities of daily living (ADLs). R1 also needed assistance with transfer from bed to wheelchair and wheelchair to bed. On September 9, 2019, R1 fell in their room sometime during the early morning hours. Charting notes revealed that after the fall at 6 am, staff found R1 on the floor in their room, next to a recliner, awake, alert and on their back. R1 was unable to express to staff how they got there from their recliner. Staff assisted R1 back to the recliner and noted an abrasion on their forehead and no other injuries. There was no evidence that R1 attempted to contact staff for assistance with getting out of the recliner prior to the fall. At approximately 9:30 am on September 9, 2019, the area of the abrasion on R1’s forehead had become swollen and, within a very short time, facility staff had R1 transported to the hospital. R1 returned the same day from the hospital, was treated for minor injuries and with no new orders. The Department’s records review did not reveal any evidence that R1 was not treated with dignity, not provided with incontinence care or that the facility failed to meet R1’s needs. The Department’s review of facility records revealed that R2 was on hospice, nonambulatory, needed assistance with ADLs and a two-person assist with transfer via a Hoyer lift. Charting notes revealed that R2 was in their room on November 24, 2019 and at approximately 6 am, R2 was found lying on their bedroom floor, on the right side of the bed and awake. At that time, R2 denied any pain or discomfort, and denied hitting their head. Redness was noted on R2's right knee, but no other injuries were noted. After complaining of pain to their hips on November 27, 2019, x-rays were taken of R2’s hips. The doctor’s conclusion after the x-rays was that R2’s pelvis was intact, there was no fracture to the hips and that R2 had mild degeneration of the hips. The Department’s interviews did not reveal any evidence that R2 attempted to contact staff for assistance with getting out of bed prior to the fall. There was also no evidence that staff did not treat R2 with dignity, failed to provide incontinence care or failed to meet the needs of R2. Interviews with staff and outside sources, and a records review revealed that, throughout September and November 2019, R1 and R2 received care from several different staff members while at the facility. During the night shift, staff #1 (S1) worked at the facility and provided care for R1 and R2. Although interviews revealed that S1 would sleep during work shifts and that S1 was later terminated for not following the facility’s policies and for attendance issues, there is conflicting evidence that S1 would only sleep during lunch breaks and other breaks, and that S1 did a good job caring for the residents. An outside source interview also revealed that R1 had a history of getting out of bed unassisted and falling, and that they received “immensely fine care” while at the facility. Outside source interviews also revealed that staff provided residents with appropriate incontinence care, would not leave them in soiled clothing or bedding for long periods of time, treated them with dignity and met their needs. Based on the evidence obtained from interviews and records review, the allegations that facility staff failed to seek medical care for resident, staff failed to treat resident(s) with dignity, staff failed to provide incontinence care to resident(s) and that Licensee failed to meet the needs of resident(s) are found to be UNSUBSTANTIATED, as there is not a preponderance of the evidence to prove that the allegations occurred. An exit interview was conducted with Administrator Donelle Williams and a copy of this report, the Confidential Names List (LIC 811) and Licensee Rights (LIC 9058 FAS 01/16) were emailed to her to the email address she provided to LPA; Ms. Williams expressed to LPA that she would send a confirmation email upon receipt of these documents.