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32 | Hospital records, observations by caregivers, and symptoms observed by witnesses reviewed and obtained by LPA contained additional descriptions of symptoms occurring. The records do not establish what information was known to facility staff when the SIR was prepared or demonstrate that facility staff intentionally altered, fabricated, or knowingly submitted false information. Although additional details were observed not indicated on the incident reports, no false information was observed on the incident reports. Regarding the allegation that "Staff did not report a resident's change in medical condition in a timely manner," LPA interviewed three staff, and three of three staff denied the allegation. Facility records documented multiple Home Health visits; an attempted Physical Therapy evaluation on 02/05/2026, physician contact regarding medication refills, and communication with R1's responsible party. Facility Notes dated 02/10/2026 documented physician follow-up, delivery of the prescription, transfer to the hospital due to a reported sudden change in mental status and submission of an SIR to Community Care Licensing. The hospital records document earlier observations of decreased alertness and neurological changes; however, they do not establish when facility staff first received or recognized those observations, when the physician or responsible party was first notified about the acute neurological change, or whether the occupational therapist's observation was communicated to facility staff. The available facility documentation indicates that the RP was contacted, and an SIR was submitted on 02/10/2026, the same date as the hospital transfer.
Therefore, based on interviews conducted, attempted resident interviews, responsible party contact, facility records, and the additional hospital records, the Department does not have a preponderance of evidence to prove that the alleged violations occurred. The hospital records confirm that R1 experienced an acute stroke and document several possible symptom-recognition times; however, they do not establish the precise time facility staff became aware of the acute change, the emergency-response timeline, or that facility staff intentionally falsified information. Therefore, the allegations remain Unsubstantiated. Although the allegations may have happened or could be valid, there is not a preponderance of evidence to prove or disprove the allegations. An exit interview was conducted and a copy of this report was provided to staff.
{***THIS IS AN AMENDED REPORT***} |