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32 | Investigation revealed the following: Staff did not follow Physicians orders, it is alleged that facility staff were giving R1 more medication (Ativan) than what their doctor prescribed. It is also alleged that R1 quickly deteriorated after admission to the facility. R1 allegedly lost weight, was sedated all the time and was unable to carry a conversation. Interview conducted with Administrator Tiffany Vander Poorten and staff revealed that facility staff administer medications to residents as prescribed by their doctors. Staff indicated that they provide residents with their medication per their physician’s orders. Administrator stated that R1's family did not want R1 taking Ativan as prescribed by the doctor. She stated that it was explained to R1's family that the facility ensures to administer medication as prescribed. Administrator and staff denied that R1 was sedated all the time. Staff stated that they ensure that residents eat all their meals and if they notice significant weight loss they ensure that the resident is seen by their doctor. Administrator stated that R1 had just been admitted to the facility on 05/08/24, was diagnosed with Major Neurocognitive disorder and had symptoms and behaviors pertaining to that diagnosis. She stated that staff would assist R1 out to the dining room to have their meals, as well as out to the living room to interact with other residents. She denied that R1 quickly deteriorated after admission to the facility and stated that when staff observed that R1 was not feeling well they informed the family and the family then decided to take R1 to the hospital and not discharge them back to the facility. Record review revealed that Ativan was a prescribed medication for R1 under their Hospice Agency standard order with an effective date of 05/17/24. Upon R1’s admission to the facility, R1’s Responsible Party R1 FM1 signed all the Hospice documentation that indicated that they were aware of R1’s Plan of Care which included R1’s prescribed medications. Interviews with 4 out of 5 residents revealed that they get their medications on time everyday and they do not have any concerns. They stated that they do not have any complaints and are satisfied with all services received. 1 resident was not interviewed as resident is non-verbal. LPA interviewed Global Home Hospice Service, Inc, Director of Nursing Soo Kim who stated that the facility was following physician's orders. R4 FM stated that R4 has lived at the facility for 6 years and they are satisfied with all services, has no concerns and the facility follows all doctor's orders as the facility is in constant communication with the family regarding anything to do with R4. Based on interviews conducted with facility staff, facility residents, hospice agency staff, resident family members and LPA review of documents there was not enough supportive evidence to concur with the reported allegation.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Exit interview held. A copy of the report was provided to Administrator Tiffany Vander Poorten. |