complaint·August 11, 2022

Review of resident's progress notes indicated that R1 was checked 3 times the day R1 was sent to the hospital on 09/17/2020. At 06:00 AM, overnight staff noted scratches below R1's hip that required itch relief, but no other changes in condition were noted. The next entry in progress notes was noted at 02:15pm, in which med tech noted no change of condition, but that R1 had complained of pain. Tylenol was administered as PRN. The final entry in R1's progress notes were recorded at 05:10pm, detailing a change of condition occurring at 03:30pm. It was noted that R1 was measured with an oxygen saturation of 60%, 911 call was made , R1 was brought to the hospital and admitted for clinical impressions of septic shock and gangrenous foot. In interviews with facility staff, 2 out of 10 facility staff stated that R1's condition had begun to deteriorate hours before the facility agreed to have R1 sent to the hospital. 8 out of 10 facility staff interviewed were unaware of or did not receive any report of change in R1's condition prior to staff check in at 3:30pm, 911 call was made shortly thereafter . 3 out of 3 AM shift staff interviewed stated that there was no change of condition observed or reported on 09/17/2020 during the AM shift. In interview with R1's responsible party (RP), RP stated that they have no reason to believe that R1 received neglectful care from the facility. RP stated that R1 was receiving care from both facility staff and home health agency and facility sent R1 to the hospital when they noticed the change. This Department has investigated the above allegation. Based on interviews and records review, the Department found that the above allegation is UNSUBSTANTIATED. An 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 reviewed and signed by Administrator Natalie Barman and a copy of the report was provided.