Complaint·April 27, 2022

It was also alleged facility staff failed to address resident's change in medical condition. An interview with OS1 also revealed R1 had been showing signs of illness for approximately 6 months and facility staff never contacted the Responsible Party or a physician, nor did they attempt to coordinate a medical assessment. The interview also revealed it was not until OS1 coordinated an appointment with a medical professional themselves that R1 was seen and diagnosed with Pneumonia and a UTI. A medical record review revealed R1 was seen by a mobile medical agency approximately twice a month. Review of medical records did not indicate a diagnosis of Pneumonia or a UTI. A facility and resident record review also revealed no documentation regarding R1 receiving a diagnosis of Pneumonia or UTI. It was alleged facility staff failed to provide R1 transportation for to medical appointments as listed in the Admission Agreement. An interview with OS1 revealed facility staff would not allow R1 access to the facility bus for transporting residents to their medical appointments, nor did they help arrange an appointment for R1 to see a dermatologist. An interview with another outside source (OS2) corroborated the facility would not allow R1 on the facility bus. An interview with another outside source (OS3) was able to corroborate OS1 arranged and provided transportation to the Dermatologist appointment that resulted in the accurate diagnosis of scabies. The facility staff was unable to provide any documentation regarding transportation for R1’s medical appointments to refute the allegation. It was also alleged facility staff failed to properly reappraise resident while in care. Based on a resident record review R1’s Admission Agreement revealed R1 was assessed at a care level of ‘0’ and also a ‘0’ level of care for medication management. The level of care scale ranges from 0 through 4, 0 being the lowest and 4 being the highest level of care. A review of facility records dated May 31, 2018 revealed R1 was documented at a personal (assistance with ADL’s) care level of 1 and a medical care level of 2. Further review of records indicated R1 received five assessments between facility admission and December 27, 2018 indicating R1 began receiving assistance with showering as od March 23, 2019, staff also began administering ointment for R1's skin condition, and also implementing universal precautions to mitigate the spread of scabies, at that time R1’s level of medical care was bumped to a level three and then returned to a level two once the scabies had been eradicated. Facility staff was unable to provide documentation of including or notifying R1's Responsible Party of changes in R1's level of care. Due to lack of corroborating evidence, the finding regarding the above allegations were established to be unsubstantiated. This finding means although the allegations may have happened, or could be valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with ED Lopez and a copy of the Complaint Investigation Report (LIC 9099) and Licensee Rights (LIC 9058 01-2016) was provided to ED Lopez, and signature on this report acknowledges receipt of the reports.