complaint·November 15, 2024

Staff changed the resident's service plan without the consent of the resident's authorized person: The allegation is that resident R1's family member (FM) does not agree with the request from the facility to hire 24x7 1:1 private caregiver for R1. On 2/22/2024, LPA interviewed previous Executive Director (PED). PED stated he/she communicated with resident R1's family member (FM) and explained to FM the reasons why R1 needs 24x7 1:1 caregiver immediately. PED stated he/she sent a letter to FM to notify FM that R1 needs 24x7 1:1 caregiver. LPA interviewed a staff S1. S1 stated resident R1 needed 1:1 caregiver due to his/her aggressive behavior. LPA interviewed a staff S2. S2 stated resident R1 needed 1:1 caregiver because he/she continued to have aggressive behavior to others. S2 stated before LPA visit, R1 was just sent to hospital due to aggressive behavior. On 2/23/2024, LPA received an email from PED which describing the incidents regarding R1. PED stated on 1/242024, R1 was confusion and with aggressive behavior to staff. On 1/25/2024, PED called R1's family member (FM) for requesting 1:1 private caregiver for R1 because R1's aggressive behavior. The reason for 1:1 private caregiver is for the safety for resident R1 and other residents in the facility. The formal letter to request 1:1 private caregiver was emailed to FM on 1/25/2024. On 1/26/2024, R1 started to have 1:1 caregiver for 10 hours daily because FM did not agree 24 hours x 7 days and wanted to limit to 10 hours daily. PED stated he/she communicated with FM and R1's another family member (FM1) that R1 needs 24x7 1:1 caregiver. PED stated FM and FM1 understood the requirement of 24 hours x 7 days 1:1 caregiver for R1. On 2/5/2024, The facility staff had a meeting with FM and FM1 to discuss R1's continuos aggressive behavior. Continue on LIC9099-C. Page 2 of 3. Based on the review of the letter that the facility sent to FM regarding the requirements of 24 x 7 1:1 private caregiver for R1, the reasons are that R1 had a change in physical and mental condition, R1 engaged in conduct that was recognized as a wander risk, and R1 engaged in aggressive behavior which poses a potential threat to R1 and other residents' safety. Based on the review of R1's incident reports, on 1/31/2024 R1 was observed walking to the exit. R1 conducted aggressive behavior to staff while staff was redirecting R1. On 2/16/2024, around 8:45PM, R1 was found yelling at R1's family member in R1's room and hitting R1's family member. R1 was then sent to hospital. On 2/22/2024, R1 was found screaming inside his/her room and R1's room doorway was found blocked, and R1's private caregiver stated it was blocked to not let R1 get out of the room to wander. R1 was then sent to hospital. Based on the interview, records reviewed, R1's had condition change, R1 had wandering behavior and aggressive behavior. The facility notified FM and discussed with FM regarding R1's issues. The facility suggested R1 to have 24x7 1:1 private caregiver for R1's safety.. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are 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. No citations noted for today’s visit. Exit interview was conducted with ED. A copy of this report was provided to ED. Page 3 of 3.