Complaint·December 20, 2024

Report Continued from LIC 9099... It was alleged that staff are not meeting the resident’s medical needs. It was reported that Resident #1 (R1) is very sick with bed sores, has sustained falls, and is not getting the care they need at this facility. The physician’s report for R1, dated 03/29/2024, lists R1's primary diagnoses as type 2 diabetes mellitus and mild cognitive impairment. The report also indicates that R1 has a history of skin conditions or breakdowns, including a stage 2 pressure ulcer on the right buttock. Although the report notes R1’s mental state as confused and disoriented, R1 is able to communicate their needs. According to staff, Buena Vista Home Health was contacted to provide wound care for R1 starting on 04/10/2024, with visits scheduled once a week. Additionally, staff communicated regularly with R1’s Primary Care Physician (PCP), continuously reporting on R1’s fall, which occurred on 04/04/2024, as well as any pain or discomfort R1 experienced between 04/08/2024 and 04/10/2024. While no injuries were noted by staff and no pain was reported by R1 following the fall, the facility staff made sure to inform the PCP about the incident. Interviews with residents revealed that staff assist when called and that residents feel their needs are being met. Residents also reported having no concerns while living at the facility. Furthermore, interviews with family members revealed that they have no concerns regarding facility staff not meeting the resident’s needs. Based on the information obtained during the course of the investigation, the Department has insufficient evidence to support the allegation of “staff are not meeting the resident’s medical needs”. Therefore, this allegations is deemed Unsubstantiated at this time. It was also alleged that staff do not administer medications prescribed. It was reported that R1 is not receiving their medication prescribed for their diabetes. Records reviewed and interviews conducted revealed that R1 was admitted to the facility on 04/02/2024 from a skilled nursing facility (SNF). Staff reported that, while at the SNF, R1's insulin was administered according to parameters and sliding scales, allowing nurses to give insulin as needed. Additionally, staff communicated with R1’s PCP on 04/04/2024 to inform them that the facility could not administer insulin through sliding scales and requested clarification on the medication administration. However, R1’s PCP declined to prescribe the same medication as at the SNF, leaving the facility unable to administer insulin. Despite R1 continuing to request insulin, staff could not proceed without the proper order from the doctor, leading to R1 being sent to the hospital to ensure their health and safety. Interviews with other residents revealed that they received their medications daily without issues. Report Continued on LIC 9099C... Report Continued from LIC 9099... Furthermore, a medication audit of randomly selected residents revealed that medications were being administered as prescribed during the visit. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff do not administer medications as prescribed”. Therefore, this allegations is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy issued.