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32 | Regarding Allegation #1: this investigation revealed that Resident #1 was discharged from a skilled-nursing facility (SNF) and admitted to the facility on 06/29/20 with a diagnosis of very poor circulation to bilateral lower extremity (BLE) left toe. Left leg/left foot – with mounds being treated by home health. Resident #1’s physical limitation: unable to ambulate due to peripheral vascular disease (PVD) exacerbation and mounds to left foot, with multiple toes acquired absence from symptoms due to poor circulation. Based on medical information provided by home health skilled nurses, home health ordered changing of the resident’s dressing every other day and then changing daily; and, home health followed up with left foot treatments. Staff #3 & Staff #4 (Med Techs) were doing the wound dressing; however, Resident #1 refused to have her wound dressing changed by the Med Techs. Administrator contacted Resident #1’s doctor who requested that the resident be sent to the hospital. Resident #1 refused to go to the hospital. Resident #1’s doctor came to evaluate its foot and decided to send the resident to the hospital on 08/23/20 for wound re-evaluation due to signs of circulation problems and infection – despite the resident being followed up by home health nurses.
Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur; therefore, the allegation of NEGLECT/LACK OF CARE: Staff not attending to residents injury as needed is found to be UNSUBSTANTIATED.
Regarding Allegation #2: this investigation revealed that Resident #1 was prescribed a narcotic medication. A review of Resident #1’s Medication Administration Record (June 2020 – August 2020) documented that Resident #1’s narcotic medication refill required a physician’s approval (triplicate order) for a narcotic medication. There are times that this narcotic medication is delayed due to being a triplicate order - three (3) approvals. Med Techs contact the pharmacy who request’s authorization from the resident’s doctor. Once the narcotic medication has been filled, it’s delivered to the facility; and, it all depends on how quick the physician responds to a request for authorization to refill the resident's narcotic medication.
Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur; therefore, the allegation of MEDICATION: Staff not refilling residents medication is found to be UNSUBSTANTIATED.
An exit interview has been conducted and a copy of the Complaint Report was provided to Administrator (Virgilio Ajas).
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