Complaint·November 19, 2024

Pg 2. Resident fell sustaining injuries due to staff neglect. On the allegation that the resident sustained a fall due to staff neglect, it is the concern of the Reporting Party (RP) that R1 has fallen a few times since R1 moved into the facility on 05/06/2023. RP stated that on 5/22/2023, R1 was taken to the ER due to a fall and brought back to the facility, only to fall again the next day. To investigate the allegation LPA Urena conducted interviews and record review. Record review of the Unusual /Injury/Incident Reports (LIC 624) submitted to the Regional Office (RO) indicated that R1 had an unwitnessed fall on 05/29/2023 at approximately 6:40 p.m. Staff found R1 on the floor trying to fix their shoe and noticed that R1 sustained two small skin tears to the top of their hand. Furthermore, on the second page of the LIC 624 indicates that Home Health was notified to provide wound care. Staff interviews revealed that they found R1 on the floor and after doing an assessment they noticed a skin tear to the top of the right hand. The staff contacted the licensee and the licensee contacted R1’s physician and home health were contacted to provide wound care to R1’s hand.Staff stated that during the day R1 was closely monitored to assist and tried to prevent falls. Record review of the Home Health “Visitor Care Notes”, revealed that Home Health was providing wound care for R1. On 07/24/2023, LPA Urena interviewed the Licensee. Per the licensee, R1 would get up at night and try to ambulate to the bathroom on their own, and this is the time when R1 sustained the falls. Night supervision is one (1) staff to six (6) residents. Motion detectors devices are placed in each room to detect residents getting up from there bed, consequently alerting the night staff. The LPA observed the motion detector monitor located in the living room and a voice is heard saying the name of the room where the movement was detected. Staff attended to the alert coming from the residents’ bedrooms. Although R1 fell and sustained a laceration to the top of the right hand due to a fall, the staff provided first aid and notified the licensee. The licensee in turn contacted the physician’s and order home health. Based on the information obtained through interviews and record review, there is insufficient evidence to find that staff were neglectful. Therefore, the allegation is deemed Unsubstantiated at this time. Continues on LIC 9099C... pg.3 Pg 3 Staff did not seek medical attention for resident. On the allegation that staff did not seek medical attention for R1, the RP stated that they visited R1 on 6/28/2023 and there were no signs that R1 was sick, however, when RP visited on 07/02/2023, R1 was unresponsive, had shallow breathing, and looked bad. RP stated that the staff didn’t know what to do and called the facility nurse. RP stated that the nurse came in and said, “What do you want me to do?” RP stated that they couldn’t believe that staff couldn’t tell there was something wrong with R1. RP stated that staff checked R1’s oxygen levels, and it was at 90%. RP stated that RP had to tell the staff to call 911. R1 was taken to the hospital, and R1 was diagnosed as having pneumonia. The staff interviews revealed that R1 appeared to be normal on the days preceding the incident, however, on 07/02/2023 R1 was lethargic during the day, however there were no signs of distress, no high temperature, skin looked normal. R1’s representative was visiting with R1 on 07/02/2023, and the representative noticed that R1 did not look well. Staff checked the R1’s oxygen level, which was measured at 90% (normal level is 95%). Staff contacted the facility’s LVN and told the LVN that R1’s representative was requesting to call 911 for R1. Staff called 911, and R1 was transported to the hospital for evaluation. R1 was diagnosed as having pneumonia. Based on the interviews, observation, record review, there is insufficient evidence to prove that staff failed to seek medical attention for resident. Therefore, the allegation is deemed Unsubstantiated at this time. Staff are over medicating resident. It is alleged that R1 was being over medicated by staff, however the RP does not know what was being given to R1 to cause R1 to appear sedated, and lethargic. To investigate the allegation, on 07/24/2023 and 11/19/2024, LPA Urena conducted record review of the Centrally Stored Medication and Destruction Record (LIC 622), and interviewed the administrator, the LVN, staff, and RP. The record review indicated that all the medications were prescribed by R1’s physician. One of the medications prescribed to R1, indicate that the side effects may be drowsiness, dizziness, nausea and headache. The staff interviews revealed that they assisted R1 with the medication per the instructions on the LIC 622. The facility LVN stated that R1 was prescribed Temazepam for agitation. The interview with the RP revealed that all medications being given to R1 were prescribed by R1's physician. Based on the information obtained through interviews and record review; staff was assisting R1 with medications as prescribed by R1’s physician. Therefore, the allegation is deemed Unsubstantiated at this time. Pg. 4 Staff are not meeting resident's needs. On the allegation that staff are not meeting the resident’s needs, it is the concern of the RP that although a home health care nurse was taking care of R1’s skin tear, RP had to take care of the wounds on the days home health nurse was not present, because the staff weren’t taking care of it properly. To investigate the allegation the LPA conducted interviews and record review. The interviews revealed that R1 sustained a skin tear on top of their hand, and Home Health was providing wound care. Record review revealed that home health was providing wound care every three days starting on 05/29/2023 through 06/29/2023. Facility staff understand that they are not skilled professional, consequently they cannot provide wound care. Staff kept wound dry by preventing it from getting wet during showers. Based on the interviews and record review, R1 was receiving wound care by a skilled professional as indicated by the physician’s orders. Therefore, the allegation is deemed Unsubstantiated at this time. No citations were issued. Exit interview was conducted. A copy of the report was issued.