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32 | 9099C(2). Allegation: Insufficient staffing resulted in staff not adequately observing resident's change in condition: Complaint alleges that resident's change in condition, including being hospitalized for high blood sugar and a Urinary Tract Infection (UTI), and a decline in eating and drinking were not observed by staff due to insufficient staffing.
Resident moved to facility on/around July 2019. Physician's Report, dated 6/18/2019, does not indicate that resident has motor impairment/ paralysis. Care plan, dated 7/1/2020, does not indicate that resident needs a mobility device. Resident's family member stated that resident did not use a mobility device and could walk independently on prior visits, and was not seen in a wheelchair until 12/22/2020. When asked, staff (S1) stated resident could walk, if staff held on to her. Interview with Administrator revealed that resident did not have a walker or wheelchair prior to being hospitalized and resident had a chair in her bedroom to use for window visits unless the visit was conducted at the activity room window. Staff (S1) stated that resident "had no change in condition - she was a little weaker but was still able to walk at that point and we helped walked her to the chair", explaining that "(R1) was tired from her shower" on 12/24/2020. Administrator stated that besides R1 "being a little slower than usual, resident did not have a change in condition and resident ate good, had no fever and that she dressed resident the morning on 12/24/2020 when she was transported to the hospital. Resident's family member stated that resident continued to decline on 12/23/2020 and by 12/24/2020 when she visited again, resident was "non-responsive" and sitting in the wheelchair like a "wet noddle". Resident's family member stated she was informed by the ER doctor that resident's blood sugar was 433, her sodium level was 166 and resident was dehydrated as she had not been eating and drinking and also had a UTI. Hospital Medical records were not available for review; however, 9-1-1 report, dated 12/24/2020 (16:57), notes that resident was assessed and determined to have high blood sugar and was transported to the emergency room.
On 12/7/2020, the facility reported a positive Covid case for a staff who tested on 11/29/2020 and received results on 12/3/2020. On 12/9/2020, (8) residents and (7) staff were tested, and on 12/10/2020, (2) residents received positive results, requiring additional staff for 14 days, through 12/24/2020. Notes from 12/11/2020- 12/17/2020 indicate that (2) positive residents were asymptomatic and the remaining (6) residents and staff did not have any Covid symptoms. On 12/22/2020, Licensee indicated that an additional staff member was quarantining at home due to a low grade fever. On 12/23/2020 (13:00), (6) staff and (6) residents were tested, including resident (R1), and results were processed on 12/24/2020(11:17 am) and positive results reported to the facility on 12/24/2020 for (2) residents and (1) staff. Licensee stated that "the results had not been received by 12/24/2020 when the paramedics came". Department notes show that Licensee reported on 12/29/2020, that positive results were received on 12/24/2020.
cont on 9099C(3)....
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