On the allegation that staff neglected a resident resulting in hypothermia, it is the concern of the reporting party (RP) that upon admission of Resident #1 (R1) to the hospital, R1 exhibited signs of being hypothermic. On 06/15/2025 at approximately 04:01 p.m., per R1’s doctor’s recommendation, R1 was picked up from the facility by the ambulance to be transported to the hospital due to R1 experiencing confusion and being lethargic. However, on route to the hospital, R1 started to experience shortness of breath, and the ambulance personnel routed R1 to the ‘nearest’ hospital to be evaluated. To investigate the allegation, LPA Urena obtained and reviewed records from the transporting ambulance company which transported R1 from the facility to the ‘nearest’ hospital. Furthermore, LPA Urena also obtained and reviewed Admission Records from the ‘nearest’ hospital.

Record review of the ambulance ledger revealed that R1’s vital signs were obtained and observed as follows: “Stable, no interventions, nor comfort measures needed on route”.

Review of the ‘nearest’ hospital Admission records revealed that R1 was admitted to the Emergency Room (ER) with suspected Sepsis: Pneumonia / Empyema, UTI, or Pyelonephritis. Furthermore, admission records revealed that vital signs were checked as follows: VITAL SIGNS: (Temp. Pulse. RR. BP)-Rate and rhythm Normal, Heart Sounds Normal, Bilateral Breath Sounds Normal, … SKIN EXAM: Skin warm, dry.

Although the allegation may have happened or is valid, based on the interviews, and record review, there is not sufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation that staff neglected a resident resulting in hypothermia is deemed Unsubstantiated at this time.