complaint·January 3, 2023

On the allegation that ‘Staff failed to meet resident’s medical needs for the OT/PT prescribed’, on 02/17/2022 LPA Walker interviewed R1 at 2:10 p.m. about needing or receiving occupational therapy (OT) or physical therapy (PT). The R1 stated that they never had OT or PT, that they had asked staff at another facility if they could get OT, but did not ask staff at Courtyard Plaza. Record review of R1’s Physician’s Report dated 02/04/2022 does not indicate that R1 needs to receive OT or PT. On 11/30/2022, LPA Urena attempted to interview the physician who signed the physicians report, but physician reported that they were unavailable. On 12/27/2022, LPA Urena contacted the physician who provided the Diagnosis Information in the Move In Record for Courtyard Plaza dated 02/08/2022. The physician stated that they would have to review R1’s medical records to provide more information about the need or recommendation for PT for R1. On 12/29/2022, LPA Urena contacted the physician a second time about R1’s medical record review, and the physician stated that they saw R1 twice during their stay at the facility. The last time the physician saw R1 was on 06/2022, and based on their physical assessment of R1, the physician stated that they had not recommended PT for R1. LPA Urena received R1’s medical records from physician’s office, and the record review confirmed the diagnosis, and medications orders as explained by the physician during the interview. Based on the information obtained through record review and interviews, there is insufficient evidence to support the allegation that Staff failed to meet resident's medical needs (OT/PT were prescribed). Therefore, this allegation is deemed Unsubstantiated at this time. On the allegation that ‘Staff failed to meet resident's medical needs (resident wants to see R1's physician as R1 states R1's medication gives R1 chest pain)’, on 02/17/2022, LPA Walker interviewed R1 about the allegation. R1 stated that they have never seen a doctor, and that the doctor comes to see them at the facility, and the doctor has prescribed their medication. Additionally, R1 stated, ‘I have not asked any staff here to see a doctor’. On 12/29/2022, LPA Urena interviewed the physician on record for R1. The interview revealed that R1 had not complained of any chest pain, consequently, the physician continued to prescribe the medications as stated in R1’s record. LPA Walker interviewed the administrator about their procedure to address residents’ medical emergencies, and any medication reactions. Continues on LIC 9099C... The administrator stated that 'if any resident ever complains of chest pain, they would immediately call 9-1-1. If the resident needs their medication, and the facility is managing it, the facility reorders the medications at least 20 days prior to running out of the medicine. If the resident is managing their own medications, the residents would tell us, and the facility staff would call the residents’ doctor if they request it'. LPA Urena conducted additional record review - Medical Administration Record (MAR's) on 01/03/2023 for R1, the record review revealed that the medication being taken by R1 did not produce an adverse reaction. Based on the information obtained through interviews, and record review, there is insufficient evidence to support the allegation that staff failed to meet resident’s medical needs. Therefore, this allegation is deemed Unsubstantiated at this time. No citations were issued. Exit interview was conducted with the facilities representative. A copy of the report was issued.