It was alleged that resident sustained injury while in care. It was reported that Resident #1 (R1) fell in their room on a table which broke and there was blood all over the table and books. Information obtained and reviewed revealed that R1 was admitted to the facility on 08/31/2021. Per R1’s Physician’s Report dated 08/20/2021, it lists R1’s primary diagnosis including hypotension, chronic systolic (congestive) heart failure, and mild cognitive impairment. Additionally, physician’s report indicated R1 was able to follow instructions, able to communicate needs, required assistance with bathing, toileting needs, and is ambulatory. Records review revealed that facility was communicating with R1’s Primary Care Physician (PCP) to report any falls R1 had had while living at the facility. Interviews conducted with staff revealed that staff would ask R1 to use their pendant if they needed to get up; however, R1 would still get up on their own without asking for help and fall. Furthermore, the facility continuously tried to lessen R1’s falls and even placed R1 on hourly checks to prevent R1 from getting out of bed on their own and getting hurt. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “resident sustained injury while in care”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was alleged that staff did not follow medication protocol as prescribed. It was reported that the facility was provided pre-measured vials of morphine and arazapan and although R1 was either hysterical or catatonic, facility staff was not administering R1’s medication to keep them comfortable. Records review of R1’s physician’s orders dated 12/15/2021, indicated to administer morphine sulfate for shortness of breath and breakthrough pain, and lorazepam for agitation and restlessness. Per R1’s progress notes, staff was contacting R1’s hospice nurse to report R1’s symptoms. At any time when a hospice nurse was not available to come to the facility, staff was given instructions to administer either morphine or lorazepam, depending on the symptoms R1’s was projecting. Review of R1’s Electronic Medication Administration Record (eMAR) revealed that R1 was being administered lorazepam for restlessness and anxiety and when R1 was having shortness of breath and pain, morphine was being administered to R1.

Continued on LIC 9099C...

It was alleged that staff did not respond to resident's call pendent timely. It was reported that R1 had pressed their pendant; however, facility staff did not respond for hours. Interviews conducted with staff revealed that caregivers are the ones that respond to the resident’s call buttons; however, if the caregivers are assisting other residents, the med-tech will assist the residents. Staff stated they have a device that notifies them when a resident has pressed their pendant. Staff stated that they try and get to the residents as soon as possible, but sometimes it might take a bit longer because they are assisting another resident or taking them to the dining room. Interviews conducted with residents revealed that they use the pendant all the time. Residents stated that it takes about fifteen (15) minutes for staff to respond, although sometimes it might take shorter or longer. Further interviews with residents revealed that staff usually respond timely to their pendant calls, and it depends on the time of day. Additionally, a resident had pressed their pendant during the interview with LPA and caregiver responded within ten (10) minutes. Resident stated the longest they have waited was about fifteen (15) minutes.

Continued on LIC 9099C...

It was alleged that staff did not afford resident respect in their relationship. It was reported that after R1 had fallen, Staff #1 (S1) could be heard in the background laughing hysterically. Records review of R1’s progress notes revealed that R1 had suffered an unwitnessed fall in their room on the morning of 12/27/2021. Per progress notes, S1 started accidentally calling R1’s family while the paramedics assessing R1. S1 stated they passed their cell phone to the paramedics to talk to R1’s family as R1 was refusing to be taken to the hospital to receive medical care. Interviews conducted with staff revealed that they try to be nice to all the residents because they don’t know what they might be going through. Staff stated that they try and cheer up the residents at times if they know that they are not having a good day for some reason. Interviews conducted with residents revealed that staff treat the residents very nicely and treat them well. Residents stated no one at the facility yells or treats them poorly. Additionally, residents stated that staff is nice and have never made them feel uncomfortable. Residents also added that staff have been courteous and treats them with respect. Furthermore, residents reported having no concerns with either the facility or facility staff. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not afford resident respect in their relationship”. Therefore, this allegation is deemed Unsubstantiated at this time.

Continued on LIC 9099C...

It was alleged that staff did not safeguard a resident's property. It was reported that R1’s debit card had gone missing. Records review of R1’s Admissions Agreement signed on 08/25/2021, Page 18 indicates R1’s Power of Attorney (POA) signed and acknowledged receiving a copy of the facility’s “Theft and Loss Policy” and on the Client/Resident Personal Property and Valuables form for R1 was filed; however, neither R1 nor R1’s POA listed R1’s debit/credit card upon admission to the facility. Interviews conducted with residents revealed that they have not had anything missing since moving into the facility. Residents stated no one usually goes inside their room unless it is housekeeping to clean; however, as soon as they are done, they leave. During an interview, resident reported thinking they had had something gone missing at one point; however, it was found later after realizing they had moved the item to another location. Furthermore, during interviews, residents reported having no concerns about living at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not safeguard a resident’s property”. Therefore, this allegation is deemed Unsubstantiated at this time.