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32 | The investigation revealed the following:
Allegation: Staff did not notice a change in a resident's condition, resulting in death.
It is alleged that R1 was observed in the dining area with blue hands, did not appear well enough to sit at the dining room table to eat and emergency personnel was not called. LPA reviewed R1’s files and facility records, there were observations a caretaker made in the dining on 3/27/26 at approximately 4:38pm that detailed R1 had unsteady gait, was leaning forward, trembling and did not seem able to feed himself, documented on charting note. There were no other drastic changes documented. Other notes indicated that on 3/27/26 at 5:34am R1 needed assistance with reinserting their catheter, at 8am a hospice nurse arrived to assist and reinserted the catheter, there were no notes stating a decline in condition. LPA reviewed R1’s Death Certificate it did not list a suspicious cause of death, additionally there are no other agencies that are further investigating R1’s death. LPA interviewed 8 staff and each denied the allegation, S4-S8 stated that they had been assigned to R1 the week leading up to R1’s passing and R1 appeared to be well, responsive, and able to eat. Interview with S1 revealed that they noticed the decline while R1 was in the dining at approximately 4:30pm on 3/27/26 and they called the MedTech to assess the resident, resident was still able to respond at this time, however, R1 did appear to have unsteady gait, was leaning forward, trembling, and did not appear to be able to feed themselves, therefore, hospice was called and a nurse arrived by 5:57pm to assess R1. LPA interviewed 6 Residents and each denied the allegation and stated they are checked on at least 4-6 times daily and if they are looking ill or not hungry staff will ask them questions to make sure they are fine.
Allegation: Staff did not seek timely medical attention for resident.
It is alleged that staff did not assess R1 after observations of R1 appearing unwell and instead waited for Hospice to arrive rather than calling 911 for assistance. LPA reviewed R1’s files and facility records, the sign in sheet indicated that hospice nurse arrived at 8am to check on R1 3/27/26, the communication log documented the purpose for the visit was to reinsert the R1's catheter and order urine bags, there were no observations of resident needing immediate medical attention noted. At approximately 4:38pm R1 was observed to have unsteady gait, leaning forward and trembling, Hospice was contacted and arrived by 6:40pm that evening, R1 was then placed on Continuous Care Treatment where a Hospice Nurse was scheduled to be by R1’s side at all times. R1 passed on 3/28/26 at 8:16pm and the assigned Continuous Care Nurse and R1’s POA were that the bedside at time of passing. LPA interviewed 7 staff and each stated that when it comes to residents on hospice the hospice agency is called first, the residents symptoms are explained and the Hospice Nurse will advise if 911 is to be called or to wait for the nurse to arrive. Staff stated that if it appears the resident needs immediate attention 911 will can be called immediately. Interview with S1 revealed that 911 was not called as during the observation of R1s change of condition as R1 was still responsive and it did not appear to be an immediate emergency, therefore, hospice was called. LPA interviewed 6 Residents and each denied the allegation, R2 and R3 stated that sometimes the staff may delay on responding in a timely manner to their call button but that is because staff may be busy attending to other residents.
(Continued on LIC9099-C)
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