Good Samaritan Home

when V9 typed R1's assessments in R1's progress note, V9 did not document correct times of when R1 was complaining of everything. V9 verified she typed everything that occurred throughout the day in one progress note right before she sent R1 out to the local hospital. V9 confirmed she should have documented R1's events throughout the day as they occurred at the correct times.On 9/19/25 at 10:43 AM V12/CNA stated, I was getting resident's up for lunch, when (R1) had put on her call light sometime between 11:00 AM and 11:30 AM. It was weird that (R1) had her call light on because (R1) is independent and never uses her call light. (V11/CNA) and I both went down to (R1's) room. (R1) was saying her eyes were bothering her, (R1) couldn't see how she normally could, and that (R1) couldn't really move her left leg. (R1) stated she was needing to go to the bathroom. (V11) and I assisted (R1) to the bathroom.

When (V11) and I assisted (R1) up to the grab bar in the bathroom, (R1) could hardly move her left leg and (V11) and I had to help guide it, to get (R1) on the toilet. (V11) went and got (V9/Agency LPN) because something was not right with (R1). (R1) never requires assistance. (V9) came to (R1's) room, but basically just told (R1) that (V4/R1's Nurse Practitioner) was already aware from the day prior and that (V9) would just monitor (R1). I am not sure how (R1) got back to her room after lunch because I was called to work on a different unit for a few hours.

When I got back to the floor (V9) had asked me if I could come to (R1's) room and help (V9) assist (R1) to the bathroom.

This was around 3:00 PM.

When I got to (R1's) room (R1) stated she now was unable to move her left arm. I believe right after that is when (V9) got (R1) sent out to the hospital.On 9/18/25 at 12:39 PM, V4/R1's Nurse Practitioner stated she saw R1 on 9/10/25 at the facility. R1 told V4 she was having cramps in her legs, and it was worse at night along with vision changes. V4 stated she did initiate orders for V4, but at that time didn't see any stroke-like symptoms. V4 stated, (R1) could move her left leg up and down when I had seen her and had no problems with weakness. I did initiate orders for (R1's) complaints of leg cramps. I would have expected the facility to notify (V17/R1's Physician) or myself right away if (R1's) if (R1) was experiencing increased weakness or required more assistance with ADL's (Activities of Daily Living).On 9/19/25 at 10:02 AM, V2/Director of Nursing verified she would have expected a nurse to notify the resident's provider immediately with any significant changes in a resident's condition like R1 was experiencing on 9/11/25 when R1 first was requiring more assistance with ADL's and complaining of increased weakness and more severe vision changes.

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