complaint·November 15, 2023

At 8:05am the administrator and LPA conducted a physical tour and health and welfare check of the facility and its residents. The LPA requested facility file documents pertinent to the investigation and noted further investigation was required prior to issuing findings. Investigator Santiago conducted interviews on 07/05/2023, at approximately 11:49am, with the reporting party; on 07/27/2023, from approximately 9:47am to 10:55am, with Staff #1 (S1) and residents; on 09/05/2023, at approximately 9:47am, with R1’s resident representative; on 09/11/2023, from approximately 1:15pm to 2:15pm, with R1, licensee, and administrator; and on 09/15/2023, at approximately 11:30am, with American Medical Response (AMR) paramedic. In addition, the investigator reviewed incident reports, Marian Regional Medical Center medical records, and facility file documents related to the investigation. LPA Brian Phillips conducted record review and interviews into the other allegations. According to R1’s physician report and preplacement appraisal information, R1 had diagnoses of depression, high blood pressure, and experienced lots of pain in arm and back. R1 had the capacity for all self-care. R1 was able to demonstrate the mental and physical ability to leave a building without the assistance of a person or the use of a mechanical device. R1 did not use a walker or wheelchair. R1 does not need help in transferring in and out of bed and dressing. R1 does not need help with moving about the facility. R1 did not require special observation/night supervision (due to confusion, forgetfulness or wandering). R1 can independently transfer to and from bed. A review of R1’s incident reports revealed that on 06/16/2023, at approximately 10:00am, R1 was noted to be progressively more confused and with hallucinations. R1 was seen by the primary care physician for confusion about two weeks prior and labs were ordered to rule out urinary tract infection (UTI). R1 reported falling out of bed early in the morning as they rolled out of their bed. The incident report noted R1 is independent with their activities of daily living (ADLs) and is ambulatory without assistance. R1 was admitted to the hospital for further testing and UTI. R1 was discharged from the hospital on 06/18/2023. On 06/20/2023, R1 was noted to have a small bump on head in the early morning, was offered to go to the emergency room (ER) but refused. On 06/21/2023, at approximately 07:25am, S1 was surprised that the fire department was at the front door looking for R1. R1 called 911 without notifying S1. R1 stated they called 911 because they felt sick and weak. According to the Marian Regional Medical Center medical records, R1 was seen in the ER on 06/21/2023 with the chief complaint of weakness. Continued on 9099-C The records noted “patient having general weakness for 4 days after a fall, seen recently and treated for UTI”. Bruising was noted on multiple areas of R1’s face that had not been documented from the recent admission on 06/16/2023 and assumed to be new. R1 was unable to recall what caused the bruising. X-rays were completed and did not reveal any fractures. R1 was admitted to the hospital 06/21/2023 and treated for Hypertensive urgency, UTI, and AKI. R1 was discharged 06/27/2023 to a Skilled Nursing Facility (SNF). During the investigation, interviews were conducted with the licensee, administrator, staff, residents, R1 and outside sources. Medical records were also obtained and reviewed. The records and interviews revealed that R1 was independent with the majority of activities of daily living (ADL's). Interviews indicated that R1 did not require close supervision and could independently navigate around the facility. R1 was alert, oriented and could communicate their needs. The staff, outside sources and R1 all corroborated that R1 did not require close supervision when navigating around the facility. Although R1 had a history of unwitnessed falls, they were during when R1 would roll off the edge of the bed. R1 was able to pick themself up and go back to bed and reported the incident to staff the following day. R1 declined to go to the hospital and did not request staff to initiate emergency medical services when they sustained bruises from the fall. R1 confirmed that R1 did not request medical services until they felt sick and weak on 06/21/2023. Furthermore, the interviews with residents denied any neglect by staff and indicated that their needs were met at the facility. Based on interviews and records review, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation “Due to neglect, Resident sustained multiple bruises” is deemed Unsubstantiated at this time. On the allegation: Staff are not providing food to resident. The Reporting Party (RP) alleged that Resident #1 (R1) stated to RP that the Staff members are not feeding R1. Interviews were conducted with the Licensee/Administrator, Staff members, residents, and various witnesses. Medical records of R1 were obtained and reviewed. Through interview and record review it was revealed that R1 was independent with majority of Activities of Daily Living (ADLs). Interviews indicated R1 did not require close supervision and could independently navigate around the facility. R1 was also alert, oriented and could communicate their needs. Staff, witnesses/outside sources, and R1 all corroborated that R1 did not require close supervision when navigating around the facility. Continued on 9099-C According to the documented Preplacement Appraisal for R1, there were no services needed regarding a special diet or observation of food intake. The RCFE Physicians Report for R1 indicated that R1 has a capacity for self-care including being able to feed self. Based on the information obtained through interview and record review, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff are not meeting resident's needs. It was alleged by the Reporting Party (RP) that Resident #1 (R1) has been left in their urine and feces all night and no Staff came to assist R1. RP stated that R1 was not able to get to the bathroom by themselves due to being sick, but no Staff assisted R1. RP stated that R1 fell on 6/16/2023, trying to get to the bathroom because staff wouldn’t come help them. RP alleged that R1 stated they did not know the last time they had been showered and that R1 is allegedly left in their room all day. Interviews were conducted with the Licensee/Administrator, Staff members, residents, and various witnesses. Interviews with the residents of the facility indicated that their needs were being met at the facility by Staff members. All residents interviewed denied any unmet needs on the part of the Staff. R1 was interviewed and stated that Staff assisted them with cleaning, showers, laundry, and medication. All residents interviewed confirmed the staff assist them with ADLs as needed, and they do not have any unmet needs. Residents reported they were frequently checked on in their rooms and assisted with medications and laundry. Although R1 had a history of unwitnessed falls, they were because R1 would roll off on the edge of the bed. R1 was able to pick themselves up and go back to bed and reported the incident to staff the following day. R1 declined to go to the hospital and did not request staff to initiate emergency medical services when they sustained bruises from the fall. R1 confirmed that they did not request medical services until they felt sick and weak on 06/21/23. Interview with Administrator indicated that R1 was taken to the hospital after R1 fell in the bathroom, which was confirmed by an employee of the Hospital. Interview with witnesses indicated that R1 was transported to the hospital because of weakness/illness. R1 had been sick and soiled themselves on the bed, but aside from this instance there are no records of R1 being left in urine and feces all night without Staff assistance. Based on the information obtained through interview and record review, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Continued on 9099-C On the allegation: Staff could not provide emergency information to paramedics. RP alleged that when paramedics arrived at the facility on 06/21/2023 to transport R1 to the hospital, the paramedics found an individual who seemed like a staff member but could not tell the paramedics anything about R1. The individual then allegedly ran from the paramedics and was not found. RP stated that it seems like the staff don’t know anything about R1. RP stated that the staff didn’t even know why R1 went to the hospital on 06/21/2023. According to an interview with Staff, on 06/21/23, a Staff member of the facility was surprised that paramedics were at the front door of the facility looking for R1. R1 had called 911 without notifying the Staff. Although R1 had a history of unwitnessed falls, they were during when R1 would roll off on the edge of the bed. R1 was able to pick themselves up and go back to bed and reported the incident to staff the following day. R1 declined to go to the hospital and did not request staff to initiate emergency medical services when they sustained bruises from the fall. R1 confirmed to licensing during an interview that they did not request medical services until they felt sick and weak on 06/21/23. R1 was offered to go to the ER on 06/20/23 but they refused. The Staff member was unaware of the reason that 911 was called on 06/21/2023. When paramedics arrived, the Staff member showed them R1’s room and went back to caring for another resident at the facility. Interview with Staff indicated that Staff #1 (S1) was told by R1 that they were not feeling well so R1 called 911 on 06/21/2023. S1 was not aware that R1 needed emergency medical services as they did not communicate it to S1. S1 only found out that R1 called 911 because the paramedics were knocking at the door. S1 was the only staff that worked that day. According to an Incident Report (SIR) received by Licensing from 06/21/2023, S1 gave the paramedics the medication lists for R1 and all recent hospitalization discharge paperwork as requested. Based on the information obtained through interview and record review, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Facility is over ratio. RP alleged that that when emergency personnel arrived at the facility on 06/21/2023 to transport R1 to the hospital, there were many people in the facility and it could be over capacity. RP stated emergency personnel could not determine who were residents, caregivers, or family members of the Licensee. Continued on 9099-C Interviews were conducted with the Licensee/Administrator, Staff members, residents, and various witnesses. Through no interview was information gathered that corroborated the allegation that there were more people in the facility than the facility could hold. On 06/23/2023, LPA received an LIS 536 Facility Personnel Report Summary from the Licensing Information System indicating the Associate Status of all employees associated with the facility was cleared. On 05/01/2023 and 06/01/2023, LPA received LIC 500 Personnel Reports from the facility indicating the Name, Job Title, and Duty Schedule of each employee associated with the facility. Based on the information obtained through interview and record review, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not provide adequate medication assistance. RP alleged that they recently discovered R1 went to the hospital on 06/21/2023 for a UTI and was given two new medications for it. RP alleged the facility doesn’t have the medications. RP stated that it is unclear who is responsible for getting resident’s medications. According to information obtained during the investigation, R1 has a history of multiple UTIs. LPA received R1’s Physician Report for RCFE, Centrally Stored Medication and Destruction Record, and Current Medication List. LPA additionally received the Hospital Discharge Summary for R1 from the hospital admission on 06/21/2023 to discharge on 06/27/2023. The Hospital Discharge Summary included a UTI diagnosis during the visit. The hospital discharge summary lists the specific antibiotics required by R1 to take along with physician instructions on correct procedures for the UTI. The Hospital Discharge paperwork also lists Past Medical history including Historical Acute UTI. R1 was given an assessment plan by the Hospital to take Amoxicillin 500mg q8h for the UTI. Discharge instructions include what the medication is for, how much to take, when to take it, and instructions for pickup and duration. All of R1’s medication is documented in R1’s Medication Dosage and Schedule at the facility as well as the Centrally Stored Medication and Destruction Record. Based on the information obtained through interview and record review, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Continued on 9099-C On the allegation: Facility is unkempt. RP alleged that that when paramedics arrived at the facility on 06/21/2023 to transport R1 to the hospital, the paramedics stated the facility was “trashed” and unclean. RP alleged that the resident’s room is unkept and resident seems to have been in the same clothes for a while. On 06/21/2023, LPA physically observed the facility and took photographic images of each area of the facility. The photographs taken by the LPA do not show the facility trashed and unclean, aside from a trash can that had not had the garbage taken out. Common areas were photographed to be appropriately furnished, with all furniture in good condition. The restrooms were photographed to be sufficiently stocked with soap, paper towels, and additional supplies. The appearance of the bathroom from the photographic evidence was in good condition. Photographs of the resident bedroom indicated appropriate furnishings and sufficient lighting. Based on the information obtained through interview and record review, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of this Complaint Investigation Report provided to the facility.