complaint·January 3, 2023

Page 2 Facility is not following hospice plan of care – UNSUBSTANTIATED It was alleged that the facility is not following a resident’s hospice plan of care. LPA reviewed Resident 1’s (R1) Hospice IDG Comprehensive Assessment and Plan of Care Update report dated 09/15/2022 and discovered that the plan stated, “ Facility needs education regarding charting of eating/elimination, med reconciliation, and follow up with hospice when change in status…i.e. bowels.” This hospice care plan does not mention a requirement for facility staff to document resident bowel movements. LPA reviewed Resident 1’s (R1) Hospice IDG Comprehensive Assessment and Plan of Care Update report dated 11/28/2022 and discovered that the plan stated “Nutrition/elimination: Intakes fluctuate, constipation issues- using Senna, MiraLAX. Nursing Plan for next 14 days: Monitor constipation- effectiveness of current bowel regimen.” This hospice care plan did not mention anything about facility staff documenting bowel movements. 3 of 3 staff who were interviewed revealed that staff are currently documenting resident bowel movements. 3 of 3 staff stated they call hospice if a hospice resident has not had a bowel movement in three days. 3 of three staff stated they dispense oral medications for bowel care if ordered by hospice but if a resident requires a suppository, they notify the hospice nurse. The administrator stated that staff documentation of resident bowel movements was not being done consistently. Administrator stated “I reviewed the hospice care plan and there isn't anything in there that directs the caregivers to document bowel movements. It says more education/teaching is needed with the staff on documentation for bowel movements.” The administrator stated They don’t currently, that is why I want to put that documentation on the MAR. Hospice asked us to verbally notify them if R1 had not had a bowel movement on the fourth day and to give R1 MiraLAX on day 4. It was determined that at the time the complaint was filed staff were not consistently documenting R1’s bowel movements. Once this was brought to the attention of the administrator, the administrator started requiring staff to document bowel movements in the MAR to ensure consistency in documentation. However, the hospice care plan does not include the requirement for staff to document R1’s bowel movements. Interviews confirmed that staff do call hospice if a resident has not had a bowel movement in 3 days and staff are dispensing medications that are within the scope of their duties. This allegation is unsubstantiated. Continued on LIC9099-C Page 3 Neglect - UNSUBSTANTIATED This allegation is too vague and broad in scope to investigate without more specific details. There was not enough information provided by the complainant. Complainant did not return LPA’s telephone call. This allegation is unsubstantiated. Personal rights - UNSUBSTANTIATED This allegation is too vague and broad in scope to investigate without more specific details. There was not enough information provided by the complainant. Complainant did not return LPA’s telephone call. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to facility administrator Sue Todd