complaint·April 25, 2024

[CONTINUED FROM LIC 9099] Care records and interviews of facility staff and outside sources showed that R1 had had Alzheimer’s Disease, was incontinent, wheelchair-bound, and required a hoyer-lift machine with caregiver assistance to transfer both in and out of bed, and in and out of wheelchair. According to R1’s hospice agency written care plan, there was an instruction for R1 to be “up to recliner 2 times a day [effective] 05/18/2022.” However, the electronic time and date-stamped nature of the hospice care plan showed that said instruction was not transcribed/written into R1’s hospice agency care plan until 07/01/2022 (the date the complaint was filed). Per the hospice agency’s electronic time and date-stamped progress notes: During April 2022, R1’s hospice care plan described “turning [them] every few hours in bed” to prevent skin breakdown. The recliner topic came to relevance after R1's responsible person expressed concern that R1 might be socially isolated if they were put back to bed (inside their bedroom away from their housemates) during portions of the day. Interviews of facility staff and hospice staff, corroborated by hospice progress notes, showed: During May 2022 through end of June 2022, R1’s hospice nurse gave repeated verbal instruction to facility staff to help R1 transfer from their wheelchair to the recliner during the day so that R1’s skin could get some relief from pressure. During this same period, facility caregivers and a manager repeatedly conveyed to the hospice agency their concern that R1’s body had become increasingly "stiff," and that transferring R1 to the recliner would negatively impact their skin instead of helping it. Facility staff expressed that they preferred to transfer R1 to bed, where R1 could be more comfortably transferred and more effectively rotated in bed. [According to the Mayo Clinic’s encyclopedic chapter on “Bedsores (pressure ulcers)”: “Friction occurs when skin rubs against clothing or bedding…and can make fragile skin more vulnerable to injury…and shear occurs when two surfaces move in the opposite direction.”] Due to R1's baseline cognitive impairment, they were unable to be interviewed by CCLD about their own care preferences. Over multiple unannounced site visits to the facility during July 2022: LPA observed facility staff use the reclining feature of R1’s wheelchair to help redistribute pressure on their body. LPA also observed facility staff use a hoyer-lift machine to transfer R1 from wheelchair to bed after lunchtime, so that their skin could get rest from pressure. Regulation requires RCFE licensees to “ensure that the hospice care plan is current, and accurately matches the services being provided, and that the [resident’s] care needs are being met at all times.” Although Licensee’s staff did not follow hospice’s specific instruction for recliner-use for R1, Licensee also timely and repeatedly communicated their reasonable basis for not doing so to both R1’s hospice team and responsible person. [CONTINUED ON LIC 9099-C, 2 of 4] [CONTINUED FROM LIC 9099-C, 1 of 4] Licensee advocated in the spirit of R1's interests and offered an alternative method for protecting R1's skin while minimizing their discomfort. Such communication also occurred via in-person care conference/meeting. Licensee continued to ensure that R1’s weight was redistributed throughout the day and indeed met R1’s skin integrity needs. Hospice care records and interviews of hospice agency staff, R1’s responsible person, and facility staff, unanimously showed: R1 had no areas of skin redness or breakdown anywhere on their body during the complaint allegation time frame, and even as of the start of CCLD’s complaint investigation on 07/07/2022. Care records and interviews of facility staff and outside sources showed that R2 had Alzheimer’s Disease, was incontinent, wheelchair-bound, and required a sit-to-stand machine and caregiver assistance to both transfer in and out of bed, and in and out of wheelchair. According to R2’s hospice agency written care plan: From 05/27/2022 through 07/11/2022, there was an instruction from hospice to facility staff to turn R2 every “2 hours with pillow support,” to include during the day. There was no specific mention in this document about R2 needing to be transferred from their wheelchair to a recliner. There was a subsequent added instruction for facility staff to “elevate [R2’s] legs 2 times per day,” which took effect on 05/18/2022. However, the time and date-stamped nature of the hospice care plan showed that said instruction was not transcribed/written into R1’s hospice agency care plan until 07/01/2022 (the date the complaint was filed). According to hospice agency progress notes: On 05/11/2022, R2’s hospice nurse wrote that they educated facility staff to “elevate patient’s legs throughout the day to decrease dependent edema.” During most of May 2022, facility staff did transfer R2 from wheelchair to recliner after lunchtime, while also encouraging R2 to elevate their feet. However, on 05/27/2022, facility staff told a hospice nurse they believed that doing both steps simultaneously (i.e., putting R2 in the recliner while also elevating their legs) contributed to R2 developing new redness on their buttocks. On 06/28/2022, facility staff reiterated their concern to the hospice agency, and by 07/01/2022, progress notes show that hospice staff and facility management reached a new consensus: after lunchtime, facility staff would help R2 lay on their side, in either their bed or on the facility’s couch, to give R2’s skin about a two-hour rest from the wheelchair. Interviews of R1’s hospice nurse and R1’s responsible person corroborated that by 07/01/2022, the affected skin on R2’s “upper left buttock” became Stage 2, meaning the top layer of skin was broken. [CONTINUED ON LIC 9099-C, 3 of 4] [CONTINUED FROM LIC 9099-C, 2 of 4] Over multiple unannounced site visits to the facility during July 2022: LPA observed facility staff help R2 to lay on their side (and not their bottom) on the living room couch after lunchtime. Staff simultaneously used pillows to elevate R2’s feet and separate their knees. In their interview, a credible outside source corroborated that facility staff also followed these steps on days when LPA was not present. Per interviews and hospice records, facility staff had requested and received from the hospice agency a Low-Air-Loss (LAL) mattress for R2 in late June 2022. Hospice progress notes showed that LAL mattress was added to R2’s hospice care plan on 06/29/2022. [According to Encylopedia.com, LAL mattresses have “interconnected air cells with a minimum depth of five inches…[allowing] air to escape from the surface of the bed.” They are proactive tools used to prevent skin pressure injuries.] Regarding the second allegation about R1’s medication: Hospice records showed R1 was prescribed a routine eye drop (for treatment of glaucoma) to be administered at bedtime every day, in each eye. However, this order was discontinued by R1's hospice physician on 07/01/2022. LPA interviewed facility caregivers and manager, who unanimously reported that while R1 took other medications willingly, they actively resisted the eye drops by doing such things as yelling out or swatting their hands. They said that staff communicated this resistance to R1’s hospice agency a few months prior to 07/01/2022, and that they continued to attempt/offer (unsuccessfully) eye drops to R1 until the discontinue order was received. R1’s hospice nurse corroborated that if R1 did not receive said eye drops, it was “probably” because R1 resisted them. The same nurse confirmed R1 had spatial vision issues, did not like being touched, and generally expressed protest by either yelling out or pushing the hands of staff away from them. R1’s responsible person confirmed that R1 was known to “wince with movement” and resisted teeth brushing as much as the eye drops. According to regulation, “Assistance with self-administration does not include forcing a resident to take medication…or otherwise infringing upon a resident’s right to refuse to take a medication.” [CONTINUED ON LIC 9099-C, 4 of 4] [CONTINUED FROM LIC 9099-C, 3 of 4] Regarding the third allegation about food presentation: Over three unannounced visits (on 07/07/2022, on 07/22/2022, and on 04/25/2024), LPA observed a four separate meal preparations and meal services at the facility. Each meal served to the residents was balanced, nutritious, and visually appealing/presentable. In their interviews, staff consistently confirmed that they were mindful to plate food portions in a presentable way. Only two of the six residents in care (who lived at the facility during the allegation time frame) were cognitively capable of being interviewed; both residents told LPA that the food served was of good quality and presentable. Multiple outside visitors were also interviewed; they said that the food served to residents was of good quality and presentable. Licenses had a sample food menu available at the facility, and it showed balanced meal offerings. Based on interviews and records, a preponderance of evidence does not exist to show that Licensee neglected the hospice care plans for R1 or R2, or that Licensee did not offer R1 their eye drops as prescribed, or that Licensee did not serve residents food that was presentable. These allegations are therefore Unsubstantiated. An exit interview was conducted with Riosa, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.