In 2015, an 80 year old woman was living at home and suffered a stroke. As a result of the stroke the woman was paralyzed on her left side an required the use of a wheelchair and 24-hour care. The woman’s ability to communicate was significantly impaired. The woman was admitted to a nursing home. The woman’s step-daughter had a health care and financial Power of Attorney (POA) but refused to provide the financial information so the woman could qualify for benefits. The step-daughter also stopped visiting the woman and would no longer return phone calls to the facility. The woman has no other family or loved ones who check on her. The facility determined after six months to discharge the woman for failure to pay the nursing home bill.

There are 45 people in the dining room for lunch. There are 5 staff members in the dinning room during this time. One of the staff members recognize that the meals coming out are not what was ordered by the doctor according to the treatment plan. One of the residents is supposed to have 1 on 1 attention while eating and is to have a soft diet. The dietary department sent out a regular diet meal. The staff member did not say anything, instead proceeded to feed the patient the meal that came out. During this time the resident struggled to swallow and began to choke. Staff members observed this in the dining room and asked the staff member what was happening, the staff member working with the resident said “Nothing, she is just being difficult” After about 20 minutes the staff member removed the resident from the table and took the resident to her room. After lunch time another staff member went into the resident’s room and found the resident unresponsive.

While on rounds a staff member could hear a resident crying in their room, the door was partially closed. The staff member could hear other voices telling the resident to be quite and stop making a scene. The staff member also overheard the person telling the resident if you want to stay here and have these people taking care of you need to sign these papers, otherwise you will be out on the street. Then the staff member heard what sounded like a slap and the person said do it now! The staff member waited until the person leave and then went in to the resident’s room. The staff member asked what was wrong and the resident said nothing, my son is a bit stressed and trying to get things taken care of. The resident appears shaken and upset and the staff member tried to comfort the resident and put her hand on the residents back by the should area and the resident flinched.