Complaint·January 14, 2025

Based on R1's evaluation/service needs and plan, it indicated that R1 did not required assistance for grooming, eating, walking, dressing, etc. After the investigation, this allegation is deemed to be unsubstantiated as there was no proof indicating the duration of R1 on the floor and there was no document indicating there was an agreement between the facility and the responsible party that the safety checks shall be completed at the beginning of each shift. Regarding to the allegation of - staff did not keep the residents authorized person informed regarding the resident's hospitalization, the reporting party stated that the facility informed him/her that R1 was transferred to the South San Francisco Kaiser due to a fall and when he/she called South San Francisco Kaiser and another Kaiser, he/she was told that R1 was not there. Subsequently, the responsible party called the facility and spoke to staff #1 (S1) who stated that he/she would get more information and call the responsible party back. However, S1 never called the responsible party instead staff #2(S2) called the responsible and by that time, the responsible party had already got a call from the hospital where R1 was transferred to. As part of the investigation, LPA interviewed the memory care director, and S1. According to the memory care director, during the transfer, the paramedics informed S1 that R1 would be transferred to Kaiser South San Francisco and the facility was not aware that R1 was being brought to another hospital until they were informed by the responsible party. The memory care director stated that S1 did not call the responsible party back because the responsible party called S1 when the shift was ending, therefore, S1 endorsed it to the incoming shift med tech (S2) to continue to follow up and called the responsible party back when additional information was obtained. LPA interviewed S1 who also reported that he/she was told by the paramedics that R1 would be transferred to Kaiser South San Francisco and stated that when the responsible party called, the shift was ending so he/she endorsed it to the incoming staff to follow up. After the investigation, this allegation is deemed to be unsubstantiated as the facility was unaware of R1's final destination which was decided by the paramedics after R1 had left the facility. However, during the investigation, the director acknowledged that staff did not get R1's vitals and report the result back to the responsible party as requested by the responsible party. This observation will be cited on Case Management visit under LIC809 and LIC809D. Although the above allegation 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 allegation is UNSUBSTANTIATED. This report is reviewed and discussed with the memory care director. A copy is provided.