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32 | Continued from LIC9099...
Staff did not assist resident after a fall and Staff did not provide adequate supervision to residents – RP alleges that R1 suffered a fall and was refused assistance from staff. Interview with Executive Director (ED) indicated that R1 suffered an injury to their thumb that resulted in a hospital visit after having a fall. Further interviews with ED indicated that R1 was assisted by staff after stating they were in pain but initially refused to go to the hospital and only consented after pain worsened. Interview with Health Services Director (HSD) indicated that R1 presented with pain due to a fall and emergency services were activated. Further interview with HSD indicated staff ensured R1’s comfort while waiting for paramedic services and resident returned from the hospital same day. Review of internal report indicated that staff activated emergency services after being made aware of R1’s pain. Review of discharge paperwork indicated that R1 was taken to the hospital the same day staff were made aware of injury. Review of Incident Reports (IRs) indicated that facility did not submit an IR to Community Care Licensing regarding R1’s hospitalization. Interviews with six (6) of six (6) staff indicated that assistance is always provided to residents who request it. Over the course of five (5) facility visits, LPA observed staff checking on residents and providing assistance when requested.
Staff repeatedly tried to charge resident for services they did not need and Staff did not ensure resident was bathed – RP alleges that facility repeatedly tried to sign R1 up for a variety of different care plans with no medical documentation by a doctor or medical professional and staff were refusing to assist R1 with bathing. Interviews with management indicated that R1 was requesting higher care needs including more frequent bathing and higher levels of supervision which resulted in various care plans being drafted and R1’s responsible party being consulted. Further interviews with management indicated that bathing frequency higher than basic services would require a new care plan and new charges. Review of resident task notes did not indicate that resident was not being refused assistance with bathing. Review of communication between facility and responsible party indicated care plans were not implemented until reviewed and signed by responsible party. Further review indicated that care plans from 2023 to 2025 did not have any changes aside from a new diagnosis from a physician. Care plans are not required to be from a medical professional and can be a result of facility observation or resident requests. Interviews with six (6) of six (6) staff indicated that staff will always assist residents with bathing as per their care plan. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated
No deficiencies cited. Exit interview conducted with Executive Director, whose signature on form confirms receipt.
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