complaint·June 11, 2024

Continued from LIC9099 LPA conducted interviews with involved parties and received inconsistent statements. Interviews with facility staff stated that they would come in to change and rotate R1 but that R1’s family would refuse to have care done. Interviews conducted with R1’s Hospice Provider stated that they saw facility staff come into R1’s room to see if R1 needed care services. Per Hospice Provider, they did not witness facility staff provide care services during their visits and believed that facility staff would wait until Hospice left to change and rotate R1. Per R1’s Hospice Provider, they did not have concerns regarding the care being provided by the facility as R1’s pressure injuries showed improvement. Review of R1’s records dated 01/18/2024, showed that R1’s stage 3 pressure injuries had improved. Review of Hospice Collaboration notes dated 01/05/2024 and 01/09/2024 corroborated that R1’s pressure injuries were improving. Review of Facility Shift Reports dated 12/14/2023, 12/17/2023, 12/21/2023, 01/01/2024, 01/02/2024, 01/03/2024, 01/10/2024, 01/11/2024, 01/14/2024, 01/17/2024, 01/18/2024, and 01/19/2024 showed when R1 was checked, changed and rotated, and when family would refuse care. Interview conducted with R1’s Responsible Party stated that there were a few days when they observed that R1 was not checked by facility staff for 8 to 16 hours, and that they changed and rotated R1 because facility staff did not do it. Per interview, care services were never refused. R1’s Responsible Party also stated that they observed facility staff come in more frequently to check on R1. Based on record review and inconsistent statements provided during interviews, the LPA is unable to determine if violations occurred. Therefore, the allegation is Unsubstantiated . A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Health and Wellness Director, and Interim Executive Director. Signature on form confirms receipt of documents.