Complaint·November 19, 2024

Documentation by the facility that escorts were provided to or refused by R1 were not available. Interviews found that R1 would at times call for and accept escorts and at other times R1 would not. Interviews of visitors for R1 found that R1 was found at times to not be using oxygen as recommended. Interviews also found that there were not clear procedures in place to ensure that, even when R1 left an area not having asked for escort, R1 was then located and oxygen assistance was offered. Therefore, there were times where R1 was not monitored as agreed to in the care plan which resulted in R1 not using oxygen as prescribed. The incidents observed did not result in R1 needing medical assistance for oxygen. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Carol Pickard . Copy of this report and appeal rights provided. Staff did not seek timely medical attention for resident- Statements made found that R1 received medical care at times when visitors insisted but R1 did not feel it was necessary. Staff were following written physician instruction for when medical care should be sought. During the course of this investigation, R1's PCP has provided further guidance. LPA advised that when R1 returns from hospitalization that clear guidance and communication is in place for the monitoring and responses to R1's medical conditions. During this investigation, R1 sustained a fall with injury. R1 had not requested assistance in getting out of bed, slipped and fell, and staff called for emergency services. LPA inspected the site of the fall after carpet cleaning had been done and did not find anything to have contributed to R1's fall. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with administrator.