complaint·June 21, 2021

The investigation revealed the following: It was alleged that on 4/22/21, S4 did not call paramedics after R1 requested and refused to address the resident's change in condition. A review of R1's physician's reports and needs and service plan shows that R1 has a primary diagnosis of diabetes and blurred vision. The hospital discharge papers shows that the resident is frequently in and out of the hospital due to these concerns. A review of the incident reports for R1 shows that he was sent to the hospital on 4/18/21, 4/22/21, 4/24/21, 4/28/21, and 5/3/21 and the visits were due to weakness, dizziness, and hyperglycemia. During interviews, R1 stated that he requested to go to the hospital but S4 refused and told him to wait until the facility nurse came in the morning. R1 stated that, due to staff's refusal, he had to ask R2 to use his phone so that he could call 911 himself. R2 stated that R1 knocked on his door asking for orange juice and to use his phone to call 911. R2 stated that R1 never mentioned that staff did not call 911 for him, but that he just requested orange juice and to use his phone. S4 stated that R1 only requested orange juice and never asked him to call 911. S4 responded to R1's request by checking his file to make sure he could have orange juice and told him to hold on a moment. He stated that R1 immediately left and was unaware that he wanted to call 911. According to the incident report dated 4/22/21, R1 made an internal complaint against S4, stating that he refused to call 911 when he requested it. S4 denied that he refused to call 911 and said that the resident only requested orange juice. S1-S4 stated that staff always call paramedics when residents request it. S1 stated that the staff did not call because the paramedics were already called by the resident. 3 out of 6 residents stated that staff seek timely medical care and address a change in medical condition for residents. Based on interviews and records reviewed the findings show that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with the assistant administrator and copy of report was provided via email.