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32 | Staff interviewed stated R1 was turned as needed. Per record reviews and interviews, R1 would refuse food/meals, and other times may eat a little of food offered. R1's diet was changed, Dr. ordered a special diet /pureed diet for R1 due to swallowing concerns and care needs. Review of records and interviews, it was found that R1 could become aggressive when staff would provide care services, such as incontinent care, and bathing/showers, but staff would provide needed care and sometimes with help from another staff, including hospice staff. Per records, staff requested a shower chair for R1, and responsible party provided one to use for. Staff interviewed stated R1 was provided hygiene care, which included dressing R1 as needed. R1 did join in activities when wanting to and staff stated they offered activities to R1 who would join if wanting to do so. As R1 declined, activities were offered as resident wanted to and/or more of a one to one, playing music, looking at pictures, talking with the resident, interacting with them, if resident was willing. Per interviews, staff deny neglecting R1 and their care needs. Staff stated they provided documents of R1 to responsible party that facility handles and charts. In summary, Director of Quality Assurance for Hospice by the Bay, stated to the LPA that Hospice staff provided care services to R1, and there are no documented issues and/or concerns filed in hospice records by hospice staff. Hospice staff had no reason to report any concerns to Department of Social Services and/or law enforcement regarding R1's care at the facility. There was no information obtained to support a violation had occurred regarding the allegations.
Per interviews, staff record reviews, and facility record reviews, staff (S4) denied speaking to residents in an inappropriate manner. Staff denied handling resident's roughly when providing care services at any time. S4 stated they are trained to handle medications and assist residents with medications as needed/ordered. S4 stated they have never discontinued a residents medication. If a resident refuses their medication, it is documented and required parties are notified. Facility has required medication assistance policies, including medication discontinue orders, and refusal of medications/missed medications.There was no information obtained to support a violation had occurred regarding the allegations.
The investigation found that there was differing information from interviews conducted, records reviewed, medical documentation, including hospice records, and information provided by the reporting party. There was no information obtained to support violations had occurred regarding the allegations.
Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "staff neglect led to resident sustaining unstageable pressure injuries, staff did not rotate resident as instructed by hospice care staff, staff did not ensure resident was adequately fed, staff left resident in soiled clothing for extended periods, staff did not provide a safe environment for resident, staff handled resident in a rough manner, staff made inappropriate comment toward resident, staff mismanaged resident’s medication, staff did not ensure resident was involved in activities, staff did not provide resident’s authorized representative with resident’s records" are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.
No deficiencies cited.Exit interview was conducted with the Administrator Paul Gozon.
"Amended" This is an amended version of the original report created on 8/29/24. |