It was alleged that R1 had a change of condition, yet the facility did not seek medical attention for R1 timely. Staff interviews revealed that approximately 2-3 days prior to 4/6/2022, R1 displayed increased moments of confusion. Per staff, R1 needed more direction and appeared less engaged in activities. Staff claimed that R1 typically was very ‘bubbly’ and that R1 appeared to be ‘down’. Staff said they spoke to R1 about their change in mood, and R1 affirmed that they were ok. Staff also reported that they would check R1’s vitals – including R1’s blood pressure – and claimed that R1’s vitals appeared to be normal. Based off the initial assessment, R1’s symptoms were similar to when someone is experiencing a urinary tract infection (UTI), thus the facility scheduled a urinalysis. According to research conducted by Alzheimer’s Society, if a person has a sudden or unexplained behavior, such as increased confusion, agitation, or withdrawal, it may be due to a UTI.

Staff interviews revealed that R1 was closely monitored prior to R1 going to urgent care on 4/6/2022. Based on R1’s symptoms, staff claimed that it did not appear that R1 needed immediate medical attention and went the route of trying to obtain a urinalysis to rule out a UTI. R1 was seen in urgent care on 4/6/2022, where notes indicated that R1 was being seen due to increased confusion and experiencing urinary incontinence for ‘the past few days’. Notes revealed that R1 presented with ‘acute altered mental status’, but differential diagnoses included delirium, transient ischemic attack (mini stroke), hydrocephalus (fluid build-up in the brain), urinary tract infection. As a result of the findings, R1 was advised to go to the emergency room for immediate evaluation. A review of hospital records indicated that R1 as admitted to the hospital on 4/6/2022 at 6:00 p.m. with the admitting diagnoses of acute ischemic stroke, altered mental status, elevated blood pressure, and high cholesterol levels. R1 did not return to the facility.

It was alleged that as a result of R1’s poor diet at the facility, R1 gained weight and developed high blood pressure and high cholesterol. A review of R1’s physician’s report dated 5/19/2021 documented that R1 weighed 127lbs. There was no indication of elevated blood pressure or high cholesterol on R1’s initial physician’s report. Hospital records on 4/6/2022 documented R1’s weight at 140lbs. Hospital paperwork noted that upon admission, R1 was found to have had a stroke, but was also found with the ‘previously undiagnosed stroke risk factors, which included hypertension and high cholesterol’. The facility would have been able to identify if R1 developed high blood pressure; however, staff reported that R1 did not have high blood pressure prior to hospitalization. However, the facility would have been unable to identify that R1 had high cholesterol prior to hospitalization without the completed lab work, as the facility does not have the capacity or equipment to monitor such levels.

Based off the information obtained, staff were not inclined to call 9-1-1 or seek emergency services as, per the facility’s assessment of R1 conducted by nursing staff, R1’s change in behavior appeared to be similar to one who was experiencing a UTI. Once the change of behavior was noticed, staff contacted the appropriate parties and R1 was evaluated at urgent care. It wasn’t until R1 received the lab work results at urgent care and was then advised to go to the hospital that it was discovered that R1 suffered an acute ischemic stroke. Symptoms of stroke according to the Mayo Clinic, include: weakness, numbness or paralysis in the face, arm or leg, typically on one side of the body; slurred or garbled speech or difficulty understanding others; blindness in one or both eyes or double vision; vertigo or loss of balance or coordination. Staff did not observe the visible symptoms of someone whom was experiencing a stroke. However, UTIs can cause sudden confusion in older people and those with a diagnosis of dementia.

Based on the information obtained, there is insufficient evidence to support the claim that staff did not provide medical assistance in a timely manner. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident not being provided medications as prescribed

Based on the investigation, there is insufficient evidence to support the claim that staff are not assisting with resident with the self-administration of medication as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff did not provide communication

Based on the investigation, there is insufficient evidence to support the claim that staff did not communicate with R1’s responsible parties. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.