Complaint·June 8, 2021

R1’s medical discharge note dated on 3/6/2021 revealed that R1 was admitted on 3/2/2021 for confusion and discharged on 3/6/21 with diagnosis of confusion due to delirium and was oriented x1 on discharged. X-ray showed left femur fracture and R1 underwent surgery and was discharged to SNF on 3/15/21. The review of R1’s needs and services plan noted that R1 is a total assist for using commode, incontinence, and toileting and requires Hoyer lift for transfer. 4 out of 6 staff stated they were aware R1 was confused when R1 returned from hospital on 3/6/2021. 2 out of 2 staff who assisted R1 on the commode on 3/6/2021 were aware that R1 was confused but still left R1 unattended on the commode citing R1 preferred privacy. R1’s interview did not confirm that R1 requested to be left alone while on commode on 3/6/21. Based on record review, and interviews, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED, which means that the allegation did occur. A deficiency was cited during visit. See LIC 9099-D. An immediate civil penalty in the amount of $500 was assessed today. Additional civil penalty in the amount of $10,000 for the violation resulting in serious bodily injury is pending review. This report was reviewed with Licensee and a copy of this report was provided. 6 out of 6 staff interviewed denied seeing, hearing, or witnessing a caregiver had sexual relations with resident. 3 out 6 staff pointed out that R1 used to have a roommate who was alert and oriented, the roommate did not complain any misconduct between caregiver and R1. R1’s relative was interviewed and did not have proof, evidence, or confidence on the identity of the alleged staff as it was based on hearsay. R1 denied having sexual relations with any staff while in care in the facility This Department has investigated the above allegation. Based on interviews, the Department found that the above allegation is UNSUBSTANTIATED. Unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. This report was reviewed with Licensee and a copy of this report was provided.