Inspector’s narrative
What the inspector wrote
If the resident had not voided, then the med tech would notify their supervisor, because this could mean the resident was dehydrated. Staff interviewed stated they encourage residents to take in liquids throughout the day, and ensured residents had cups of water accessible to remain hydrated. However sometimes the residents do not take in the liquid provided. When this happens, staff notify the resident’s family and doctor, and the administrator. Staff stated by the third day of a resident refusing to take in liquids, the facility would send the resident to the hospital for evaluation. Staff stated they are trained to look for signs of a Urinary Tract Infection (UTI), which could include increased confusion, not eating, and an odor. Staff also stated they notify the resident’s family and doctor for any change in condition. Staff stated they did not recall specifics about R1’s bowel movements. However, one staff stated they remembered R1 drank lots of liquids and urinated a lot. R1 asked for fruit smoothies often, and indicated R1 finished every drink staff provided them.
Former Administrator stated they recalled R1 wore briefs due to incontinence and required a two-person assist to change the briefs. Former Administrator stated R1 would have been changed before and after meals. Former Administrator did not recall R1 having an issue with constipation, nor remembers discussing with staff that R1 was not urinating or defecating. Former Administrator stated staff knew to report something like that to her. Former Administrator also stated staff knew to report if a resident was not eating. R1 was declining foods but was still drinking smoothies, Ensure, and water, and Former Administrator was never informed R1 had stopped taking liquids. Former Administrator stated R1’s family knew R1 was not eating solids, and allegedly told Former Executive Director that R1 could consume smoothies instead. Former Executive Director stated R1 liked milkshakes and would ask for things to drink. Former Executive Director also noted that beverages are also given out even when not requested, to keep residents hydrated. Former Executive Director noted R1 preferred liquids over solids more than most residents. It is documented in hospital records on 1/5/21 (prior to facility admission) that R1 “really likes the protein shakes, does not like solid food, poor appetite.” Hospital records also showed that R1’s family was aware they preferred liquid foods to solids before R1 moved into the facility.
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R1’s care plan dated 1/10/21 also notes that R1 like smoothies, staff should encourage R1 to eat as much as they can, family states R1 is not eating much, and please encourage liquids and smoothies.
Bowel logs for R1 were unavailable at the time of the complaint. Bowel logs reviewed in July 2022 showed that several of the logs were incomplete, with several having entries only for the morning shift. Hospital records indicate R1 had clinical signs for dehydration that included dry mucous membranes, tachycardia, and abnormal vital signs. R1 required a large volume of rapid fluid resuscitation through IV. However, a hospital physician who treated R1 was interviewed and stated R1 had urine retention, but was still making urine and therefore was taking in fluids due to the amount of urine in their bladder. Based on the information obtained, there was insufficient evidence to prove the resident was dehydrated. Therefore, the allegation is deemed Unsubstantiated at this time.
On the allegation: Due to neglect, Resident suffered a fall while in care.
It was alleged that due to a lack of care and supervision, R1 sustained a fall while in care at the facility. R1’s care plan dated 1/10/21 indicates they are a “fall concern,” and they required total assist with ambulation. Staff interviewed stated R1 was checked on every one to two hours. Multiple staff interviewed did not recall R1’s fall. R1 did not require a one to one staff person. R1 fell alone in their room and was found on the floor by staff on 2/1/21 at approximately 2:50pm. Staff called 9-1-1 and sought medical attention for R1, who complained they were in pain. Based on the information obtained, there was insufficient evidence to prove that a lack of care and supervision lead to R1’s fall. Therefore, the allegation is deemed Unsubstantiated at this time.
On the allegation: Resident was vaccinated without consent. It
was alleged that R1 received a COVID-19 vaccination without consent. R1’s family member (F1) stated they were notified that residents in the facility would receive the COVID-19 vaccine.
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F1 stated they promptly contacted the facility to inform them R1 was previously diagnosed with COVID-19 one month earlier, and per Centers for Disease Control (CDC) guidelines, they should not be vaccinated for at least 3 months after being diagnosed. Per F1, the facility informed them the guidelines had changed and it was ok to give R1 the vaccine, so R1 received it. Per F1, the next day R1 fell out of their wheelchair, landed on their back, and went to the hospital. F1 stated they believe receiving the vaccine they did not need caused R1’s health to decline. Faily member 2 (F2) was interviewed and stated R1 received the first vaccination dose in the hospital and did not respond well. F2 stated based on that and CDC guidance, they told the facility R1 should not receive the second dose. F2 was unaware that the facility vaccinated R1. Resident’s vaccine card and vaccination status were not provided in the documents obtained. There was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time.
On the allegation: Facility did not notice a change in resident’s condition.
R1’s family member (F2) stated that although R1’s condition declined, R1’s responsible party was not notified of the decline that occurred during their last 2 weeks at the facility. F2 stated the facility did not inform them that R1 was not eating and was not voiding, and that their health was declining. F2 believes that R1 not urinating or having bowel movements should have been an indication something was wrong. F2 also indicated R1 had a history of not wanting to eat, which started at the prior Skilled Nursing Facility (SNF). It is documented in hospital records on 1/5/21 (prior to facility admission) that R1 “really likes the protein shakes, does not like solid food, poor appetite.” Hospital records also showed that R1’s family was aware they preferred liquid foods to solids before R1 moved into the facility. R1’s care plan dated 1/10/21 also notes that R1 like smoothies, staff should encourage R1 to eat as much as they can, family states R1 is not eating much, and please encourage liquids and smoothies. Staff interviewed recalled that when R1 first moved in, they ate any of the food prepared. However, staff stated there came a time when R1 did not want to eat any more. When this happened, staff offered R1 other options, and noted that R1 liked juice and would often as for it.
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Staff also stated R1 was never combative, which could have been an indicator of a UTI. Former Executive Director stated when making rounds on 2/1/2021, they noted R1 “didn’t look so good” and was pale, and did not seem like themselves. The morning shift had not reported any changes with R1. However, Former Administrator stated R1’s baseline was very weak and R1 could barely talk. Former Administrator indicated they did not feel that R1 was declining, and they appeared the same throughout their time at the facility. The Emergency Medical Services report only states R1 was transported due to being found of the floor, and does not note any additional concerns about R1 or their appearance.
Bowel logs for R1 were unavailable at the time of the complaint. Bowel logs reviewed in July 2022 showed that several of the logs were incomplete, with several having entries only for the morning shift. The facility did not chart fluid intake on any written document, but the hospital physician confirmed they believed R1 drank a lot of fluid based on the amount of fluid in their bladder upon admission to the hospital.
F2 stated the facility was not proactive in communicating with family. When F2 called, they asked staff how R1 was and was not notified she was declining. F2 believes R1 had to decline in order to be sent home on hospice after being in the hospital. However, R1’s ER doctor stated R1 should have been on hospice when they entered the facility, and staff stated they did not notice any change in condition. Although the allegations may have happened, there was insufficient evidence to prove the allegations occurred. Therefore the allegations are deemed Unsubstantiated at this time.
On the allegation: Facility not allowing resident to communicate with family members.
It was alleged that R1 was not allowed to have visitors due to COVID-19 restrictions. R1’s family member (F1) stated they had some phone calls with R1 and a couple of Skype calls. However, the last two weeks R1 was at the facility, they had no contact. Per F1, staff stated R1 was sleeping when they called, or no one was available to initiate the call or the iPad was not available. Interview with R1’s family member (F2) revealed due to COVID-19, they were able to call R1 but sometimes no staff were available to assist R1 with video calls.
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Upon re-interview, F2 stated staff would say R1 was sleeping, bathing, or eating dinner when they called, or the iPad was unavailable. However, no other interviews corroborated this information. Although the allegations may have happened, there was insufficient evidence to prove the allegations occurred. Therefore the allegations are deemed Unsubstantiated at this time. Technical assistance is provided to the facility to ensure there are adequate and competent staff to allow residents to communicate with family members via telephone or video conference platforms.
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