complaint·March 7, 2024

The investigation revealed the following: Allegation: Staff admitted resident without resident's consent. It is alleged that Resident #1 (R1) was admitted to the facility by unauthorized individuals. Per information gathered on hospital records, hospital that transferred R1 to facility, it was stated that R1's brother was the Power of Attorney (POA). LPA interviewed brother of R1 and they stated that they are not and have never been a POA for R1, however, they are the next of kin and the Responsible Party for medical decisions for R1. R1's brother further stated that R1 at the time of admission was in recovery and unable to make their own decisions, therefore, R1's brother made the decision of admitting R1 to facility and signed all paperwork to do so, R1 was aware of the move and went willingly. R1's Physician's report dated 5/19/23 states that R1 "is not decisional for medical care", and indicates that bother assists with medical decisions. Allegation: Staff did not follow the facilities visitor policy. It is alleged that the facility did not follow visitor policy as the required sign out was not done. LPA obtained a copy of the facilities visitor policy and no where in the policy does it state that one must sign in and out during visitation. LPA interviewed Administrator and 1 Staff and both stated that facility allows visitation with family members and friends, facility encourages these visits and that all staff are aware of who the responsible parties for each resident are and would not allow residents to leave without proper supervision if needed. LPA interviewed 2 residents and both stated that they are allowed visitation with family and are able to leave into the community with their responsible parties/family. Allegation: Staff allowed resident to leave the facility without verifying appropriate supervision. It is alleged that R1 left the facility unassisted with girlfriend and staff did not follow behind R1 to ensure safety. LPA reviewed admission agreement for R1 and girlfriend identified as wife on paperwork was indicated as a responsible party for resident. During interview with R1's brother/Responsible Party, they stated that although girlfriend was not able to make medical decisions for R1 visitation was granted as family lives out of state and girlfriend lives near by and is able to be a support for R1. LPA obtained a copy of a signed letter from R1's girlfriend stating they are taking R1 from facility on 6/10/23. Administrator stated that since girlfriend was listed as a responsible party during admission she was able to take R1 from facility, there fore, R1 left facility supervised with their Responsible Party. (Continued on LIC9099-C) Based on statements and interviews conducted with staff and residents, review of R1's files and facility Visitation Policy, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided to Caregiver Myra Johnson.