complaint·June 11, 2024

On 3.11.2024, 3.18.2024, and 4.5.2024 LPA Leslie Ngo-Castaneda requested medical record. Medical records were reviewed on 3.18.2024, 3.25.2024, 4.2.2024, 4.5.2024, 4.8.2024, 4.12.2024, and 5.9.2024. On date an interview was conducted R1s Nurse Practitioner. Allegation: Staff did not seek medical care for resident. It is alleged that R1 needed surgery for a diagnosis that effects the brain and staff did not seek medical attention. The interview with R1 revealed that the facility staff assists with making and arranging for medical attention including appointments and any follow up medical recommendations. In interviewing the Administrator there may be times when R1 does not want to go for their scheduled appointments and will decline to go and a new appointment will be scheduled, again R1 will decline. R1 acknowledged and indicated that scheduled appointments have been cancelled by them. The facility continues to assist the resident and will follow up with the doctor for in person visits. R1 has no issues with the facility a believes the facility is assisting with their medical needs. LPA reviewed R1 medical records and interviews with R1s (Nurse practitioner). Based on the medical records reviewed, it appears that the resident has had all appropriate test completed to address their medical condition that effects the brain. Interview with the nurse practitioner reveals that the facility has done what they can and that the resident condition is within normal pressure and medical specialist follow-up appointments and recommendations are followed. Since R1 was diagnosed, R1 has been continuing receiving care for treatment from a medical specialist. Interview with other residents revealed they are satisfied with the assistance being provided; no complaints expressed. Based on information obtained through interviews and record review this allegation is deemed unsubstantiated at this time. Continue to LIC 9099-C Allegation: Licensee refused to release medical documents after receiving a medical consent form. It was alleged that the licensee refused to release medical documents after receiving a medical consent form. Per staff interviews and records review, all staff are trained on releasing confidential information/Health Insurance Portability and Accountability Act (HIPAA). LPA conducted records review for R1, LPA observed the original Release of Client/ Resident Medical Information- LIC605A in R1’s file unsigned. During the course of the investigation, a copy of LIC 605A was presented to the LPA, signed, and dated 12.3.2023. LPA interviewed R1 on 3.8.2024. The interview revealed that R1 did not give consent to any individual for medical information to be released and stated they only speak for themselves. LPA showed the LIC 605A to R1 who verified the signature on the form was not theirs. R1 indicated that the form was signed by someone else who was not given consent to obtain confidential information or medical documentation. Because of this, facility staff did not release any medical documents or other confidential information. The interviews and documentation review do not corroborate this allegation. Therefore, the allegation is unsubstantiated at this time. Exit interview conducted. Copy of report delivered to Administrator.