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32 | thrombosis, and mild cognitive impairment. The physician’s report indicates R1 does not have bowel or bladder impairment, uses a wheelchair and is unable to walk, is unable to bathe self, and needs assistance with toileting needs. The facility identified R1 as a fall risk when asked about residents who are a fall risk. R1’s assessment indicates they need “extensive” assistance with mobility/ambulation/escorting, and “requires hands on assistance by staff member.” The assessment indicates R1 can only walk 2-3 steps and requires total assistance, needs “total transfer assistance, lifting required,” and needs toileting assistance “extensive: resident requires toileting/incontinent checks during waking OR nighttime hours.”
R1’s responsible party (RP) was interviewed regarding the falls. RP stated they were aware of R1 falling a couple of times trying to go to the restroom on their own, because staff did not assist R1 even after they used their call button. LPA reviewed incidents reports for R1. LPA observed multiple incident reports for issues unrelated to falls. LPA observed an incident on 10/31/2020 where R1 was found on the floor by their bed. The incident stated the facility investigated the fall due to possible resident neglect. The facility filed an SOC 341 suspected abuse form on one of their staff, Staff 1 (S1), and informed the Ombudsman and police. LPA interviewed Director of Operations about S1’s personnel record and the information it contained about this incident, and reviewed relevant documents. The information revealed on 10/31/2020, it was reported thatR1’s call button was not responded to despite calling 9 times and R1 was found on the floor at 10:30 pm. S1 stated they checked on the resident between 9:20 pm and 9:30 pm. S1 stated they did not see any call light, that their beeper was always on, and they never let the lights go unattended. The internal investigation notes revealed R1 was found undressed and their nightgown was wet. S1 resigned on 11/7/2020. Based on the information obtained from the incident report, interviews and the facility’s internal investigation, the allegation is deemed Substantiated at this time.
On the allegation: Staff did not ensure Resident had access to meal(s). It was alleged that residents did not get adequate food or beverages during the COVID-19 pandemic when food was delivered to the rooms. LPA reviewed the staff schedule for May 2021. The schedule indicates one cook in the morning from approximately 5:30 am to 10:30 am most days. Then there is another cook 10 am to 7 pm. Tuesday 5/11/2021 indicates no morning cook, and only a cook from 10:30 am to 7 pm. The schedule shows 1 or 2 servers for breakfast, 1 to 2 servers for lunch, and 2-3 servers for dinner. One resident interviewed indicated they had experienced delays in being served before, and stated they waited over an hour for lunch on 5/16/2021. LPA interviewed Resident 1 (R1)’s Responsible Party (RP), who indicated they visited R1 at least once where R1 was in a chair, and food was left on a table far away that R1 was unable to access on their
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