complaint·January 7, 2022

Regarding allegation: Personal Rights: Severe neglect resulted in resident requiring hospitalization. Hospital record review revealed R1 was taken to the hospital on 02/01/2020 due to the primary complaint of confusion and cloudy urine and R1 was admitted to the hospital. R1 was found to have Leukocytosis and an abnormal urinalysis. R1 was discharged on 02/05/2020 with a discharge diagnosis of Metabolic encephalopathy and urinary tract infection. Interviews with the Administrator revealed, Resident #1 (R1) was hospitalized on 02/01/2020 due to a urinary tract infection and began receiving home health care services after they were discharged from the hospital. Prior to the hospitalization, the Administrator stated R1 wore adult briefs during the day and the night but was assisted with toileting every 2 hours. Although, R1 would sometimes refuse to be toileted and hold their urine. The Administrator stated the resident liked to drink fluids and needed to be changed and showered often. Based on the information obtained, there is insufficient evidence to support the allegation of Personal Rights: Severe neglect resulted in resident requiring hospitalization. Therefore, the allegation is deemed unsubstantiated at this time. Regarding allegation: Personal Rights: Resident sustained a pressure injury The allegation alleges on 02/28/2020, Administrator Edna Dangiapo advised R1’s family member that R1 had a blister on the right heel due to increased swelling of their feet and to obtain a new pair of shoes for R1. R1 was moved out of the facility on 02/29/2020, to a new facility. The home health agency later advised the wound was a pressure injury and not a blister. Home health record review revealed R1 received home health services from 02/07/2020 through 02/19/2020. The principle diagnosis was urinary tract infection and unspecified dementia. Records indicate no presence of any pressure injuries. Care was ended with this provider on 02/19/2020, when the family member decided to use a different provider. R1 began care with the second home health agency beginning on 02/20/2020. On 02/25/2020 a skilled assessment of all body systems was conducted by a RN and no redness or open wounds were noted. On 02/28/2020 a skilled assessment of all body systems was conducted by a RN and no redness or open wounds were noted. The next assessment by the home health agency was conducted on 03/03/2020 and R1 was diagnosed with a stage 1 pressure ulcer on the right heel. Report continued on LIC 9099-C. During the interview with the Administrator they stated R1 did not have any pressure injuries and only had a blister on their heel from their brand new shoes. Based on the information obtained, there is insufficient evidence to support R1 sustained a pressure injury while in care, as R1 was not diagnosed with a pressure injury until 03/03/2020 and R1 moved out of the facility on 02/29/2020. Furthermore, R1 was assessed by the home health agency on 02/28/2020, and there was no record of a pressure injury being present. Therefore, the allegation of Personal Rights: Resident sustained a pressure injury is unsubstantiated at this time. Regarding allegation: Staff failed to address resident's incontinence needs The allegation alleges when R1’s diaper was changed in the emergency room, R1 was triple diapered and had a red rash and pungent smell from the diaper area. Interviews with the Administrator revealed R1 was taken to the emergency room by a family member due to suspected urinary tract infection as R1 had a low grade fever and strong urine smell. The Administrator stated they instructed staff to use a pull up and a diaper on R1 prior to going to the emergency room as they were concerned R1 would be waiting in the emergency room for a long period of time prior to being seen and the Administrator did not want R1 to soil them self and need to be changed in the emergency room bathroom. The Administrator denied double diapering R1 otherwise, and stated R1 was taken to the toilet every two hours and changed as needed. Hospital records reviewed did not indicate any concerns regarding R1’s incontinence care. Based on the information obtained, there is insufficient evidence to support the allegation of occurred. Therefore, the allegation of Staff failed to address resident’s incontinence needs is deemed unsubstantiated at this time. Regarding allegation: Staff failed to address resident's dental needs. The allegation alleges R1 was observed with a gray, blackish film on their teeth while in the hospital despite R1 having a full dental cleaning in November 2019. Interview with the Administrator revealed when R1 moved into the facility in November 2019, R1 had observable oral hygiene issues and their breath smelled. The Administrator stated they gave the family member of R1 contact information for a local dentist to address the resident’s needs and R1 had a teeth cleaning. The Administrator stated staff did their best to brush R1’s teeth but R1 was resistant to care and would not always open their mouth and allow staff to brush R1’s teeth. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff failed to address resident’s dental needs is deemed unsubstantiated. Report continued on LIC 9099-C. Regarding allegation: Staff failed to ensue resident was properly groomed while in care. The allegation alleges R1 was seen on a Monday and observed in the same outfit on the following Wednesday. Interviews with the Administrator revealed R1 had a variety of clothes to wear and stated R1’s clothes were changed daily. Based on the information obtained there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff failed to ensure resident was properly groomed while in care is deemed unsubstantiated at this time. Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights were emailed.