Complaint·July 10, 2024

Staff called 911 immediately while applying pressure to the wound. R1 was diagnosed with a laceration on their head that was cleaned and sutured as well as hematomas on their hips. R1 was discharged back to the facility the same day of this incident at 6:15a.m. as no further head injuries were assessed at the hospital. LPA received a copy of the resident's discharge summary from the hospital on 05/25/2023, due to a fall causing head trauma and a laceration of the scalp requiring scalp sutures. Medical tests conducted were CT of the brain, CT of the cervical spine, ECG, X-Ray of the chest, and X-Ray of the left forearm. The reporting party/complainant corroborated this version of events during an interview with the Licensing Agency on 06/12/2023, and stated R1 needed stitches on their head and sustained multiple bruises on their hips. Based on the information obtained, there was insufficient evidence that due to neglect, resident sustained an injury while in care. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not seek timely medical treatment for resident. It is alleged that Resident #1 (R1) had an ingrown toenail on their left toe and that the injury was ignored for two (2) weeks with no treatment being requested for R1. The allegation states that two (2) weeks later R1 sustained a bad infection on their left toe and R1 was seen by an attending physician who cut R1’s toenail and prescribed antibiotics. LPA received signed and dated documentation beginning in December 2022 of a Professional Medical Services Agreement between the facility and a board-certified medical Doctor licensed in the State to provide wound care services to the residents of the facility. This Doctor exclusively provides wound care services referred to by the residents’ primary physicians and does not act in any other capacity. LPA received Physicians Orders/Audits from the primary care physician of the resident dated from 04/28/2023-06/20/2023 on a consistent basis (every day to every other day/occasionally every 3 days). LPA received copies of Medical Services provided to the resident from 06/20/2023, regarding an ingrown toenail infection. There is no evidence through record review that R1 was ignored for two (2) weeks with no treatment on the ingrown toenail. Through interviews with Staff, LPA found no evidence that R1 was ignored for treatment on the ingrown toenail, and all Staff interviewed stated R1’s ingrown toenail was provided treatment appropriately. There is no evidence through either record review or interview any medical treatment needed by R1 was delayed or ignored. Based on the information obtained, there was insufficient evidence that due to neglect, resident sustained an injury while in care. Therefore, the allegation is deemed Unsubstantiated at this time. Continued on 9099-C On the allegation: Due to neglect, resident sustained drastic weight loss while in care. It is alleged that Resident #1 (R1) experienced a drastic weight loss and decline in condition while in care at the facility. The allegation states that the facility explained the weight loss as side effects from physician prescribed antibiotics for R1. Through record review, LPA requested and received a Diet Change Form for Personal Care for R1. This Diet Change form adds a protein/health shake to every meal for R1 to address weight loss caused by the antibiotics. The Diet Change Form is signed and dated 06/15/2023. Through Staff interview, LPA learned that the facility attempted to mitigate the side effects of the physician prescribed antibiotics through meal service changes to R1. LPA requested and received documentation of the antibiotics prescribed to R1 in which a side effect is noted of weight loss/loss of appetite. R1’s weight was being monitored by the facility and actions were made to address the weight loss of R1 through the side effect of the physician prescribed antibiotics. LPA received detailed Doctor's Progress Notes from 05/26/2023, 06/02/2023, 06/05/2023, 06/13/2023, & 06/16/2023. LPA also received documentation of the facility 24 Hour Chart Check for the Resident for the months of May and June 2023. These documents had noted the weight changes in R1 based on the side effects of antibiotics and the responses by the facility. Based on the information obtained, there was insufficient evidence that due to neglect, resident sustained an injury while in care. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not provide adequate assistance to resident in care. It is alleged that Resident #2 (R2) needs constant assistance from facility staff due to their medical diagnosis and physical health impairments. The allegation states that staff are not checking up on R2 regularly, and that staff rotate constantly with different staff shifts providing different levels of care to R2. This has allegedly caused R2 to wander into other resident’s rooms as well as defecate in the hallway of the facility. LPA Phillips conducted complaint investigation visits to the facility on 06/21/2023 and 07/01/2023. During these visits, LPA requested and received relevant documents to the allegation for record review. The Physician’s Report for Residential Care Facilities for the Elderly (RCFE) for R2 dated 09/17/2021 indicated that R2 had a physical health status of macular degeneration causing blindness, auditory impairment, and bladder impairment as well as a diagnosis of dementia. Continued on 9099-C On 09/25/2023, Licensing Agency received an Incident Report from the facility stating that R2 was transported to the hospital via 911 for weakness, lethargy, and disorientation with the family members of R2 being notified. The incident report indicated that R2 was discharged the same day with their relative into the facility Skilled Nursing Facility (SNF). On 09/29/2023, Licensing Agency received a telephone call from Long Term Care Ombudsman that indicated R2 is emotionally unstable at times and loses their sense of knowing where they are at times. The Long-Term Care Ombudsman stated that R2 was sent to the hospital via 911 on 09/25/2023 alone with no staff accompanying them for approximately six (6) hours. The Long-Term Care Ombudsman stated the facility staff did not acknowledge or make necessary actions for someone with R2’s medical diagnosis/physical health impairments that has different needs. However, it is standard procedure/protocol at an RCFE when a resident is sent to the hospital for no facility staff to accompany them during the trip. The facility SNF Observation Report of R2 dated 10/04/2023 indicates that the facility noted a history of wandering by R2 and that R2 needs assistance with all Activities of Daily Living (ADL). The Clinical Notes from the visiting Hospice Care agency on 10/04/2023 indicated that facility staff explained that R2 is a fall risk but won’t stay in their chair or seated walker. Staff said R2 gets up to try to walk every few minutes, and that it may be needed to change R2’s Plan of Care at the facility. The Clinical Notes from the visiting Hospice Care agency on 10/14/2023 indicated R2 spends quite a lot of time walking around the facility living room and dining room area. Staff stated to Hospice Agency Representative that R2 needs continued reminders to use a walker or for redirection. The facility SNF Observation Report of R2 dated 10/18/2023 indicates that encouragement is needed for additional caregiver to assist with R2’s needs. The facility implemented a bedroom sensor/floor alarm in R2’s bedroom to alert facility staff anytime R2 leaves their bed. On 04/05/2024, the facility Resident Progress Notes stated that R2 was found sitting on the floor next to their bathroom entrance by Staff. R2’s bedroom sensor mat/floor alarm had not been triggered to alert staff when R2 got out of their bed. However, R2 was frequently checked on by staff who observed this despite the bedroom sensor/floor alarm. R2 denied pain and was assessed with no injuries by R2’s attending physician. Based on the information obtained, there was insufficient evidence that Staff did not provide adequate assistance to resident in care. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of report provided to facility.