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32 | Physician visit dated 04/15/20 listed the chief concern as Progressive Major Neurocognitive Disorder with behavioral disturbances. That report was signed by the physician stating to monitor R1 as every visit there’s more isolation and yelling. Physician visit dated 06/25/20 noted R1 was still very agitated, yelled, and slammed doors. Facility records reflected another one of R1’s physicians wrote a prescription for Haldol on 08/17/20. Facility progress notes dated 08/18/20 reflected R1’s aggression, as R1 was seen striking another resident on their left shoulder with a closed fist. R1’s responsible party was notified and stated they were fine with medication intervention to alleviate aggression. The facility was following physician’s orders and did not note negative or sedative effects of the medication.
The facility was following physician’s orders as prescribed. Staff interviews revealed they did not witness R1 appear groggy or sedated. Therefore, there were no changes to report besides the increased aggression. An outside source interview revealed R1 was falling asleep while eating. A review of R1’s medical records showed R1 was being evaluated and the physician did not state R1 appeared sedated. Staff admitted R1 would eat with their eyes closed and open them once finished. On 09/08/20, the Facility’s progress notes reflected a new order to increase Haldol. Facility progress notes dated 10/01/20 documented notification of R1’s responsible party regarding R1’s behavior and aggression towards staff, and residents. R1’s physician requested to get a psychiatrist to see the resident and stop medications Haldol and Seroquel because resident was allegedly salivating. Facility staff interviews denied R1 was salivating.
Another notification was sent to R1’s responsible party on 10/02/20 indicating medication change to discontinue Haldol and was recommending another medication, the responsible party agreed.
There were multiple communication notes and documentation from the facility to R1’s physician and responsible party notifying them of changes with R1. In addition, R1’s responsible party acknowledged the communication correspondences, each time they were notified of any changes with R1. Most changes were R1’s aggression towards others. On 10/22/20, R1’s responsible party documented when R1 was weaned off Haldol, R1 started yelling and getting angry whenever they had a conversation. R1 was receiving medications as prescribed and the responsible party and physician were made aware of R1’s conditions, which was why the physicians were adjusting R1’s medications. A review of R1’s medical records and interviews indicated the facility was in constant communication with R1’s responsible party and physician.
During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Brigitta Lofvendahl whose signature below confirms receipt of these rights. |