Complaint·December 16, 2024

On April 15, 2024, the Department received an incident report (IR) regarding R1. The incident report stated on April 9, 2024, R1 arrived in a wheelchair to the day program. While assisting R1 from his/her wheelchair, staff noticed R1’s legs were swollen and was experiencing pain. Program Coordinator (PC) called R1’s responsible party and informed him/her of the observations. PC let R1’s responsible party that 911 would be called for R1. When 911 arrived R1 was still having a hard time ambulating and when placed on gurney, PC noticed his/her left leg had a quarter size bruise and fresh blood dripping down his/her leg. Later in the day PC spoke with Kingdom Hearts Staff S1 regarding R1’s swollen legs. S1 told PC it was normal for R1’s legs to be swollen and that it was a waste of resources to send R1 to the emergency room. PC told S1 it was different that day and R1 was complaining about pain. On April 25, 2024, Licensing Program Analyst Manuel Monter interviewed staff S1. S1 stated he/she mentioned to the day program that he/she didn’t want R1 transferred unnecessarily to the hospital and use resources unnecessarily. S1 stated a few weeks ago, the day program had R1 sent to the hospital. S1 stated after he/she was sent there, the resident returned with no issue. S1 stated he/she told the day program it was their call because they can see the resident in front of them. On December 4, 2024, Licensing Program Analyst Manuel Monter interviewed Day Program ADM (DADM) and Day Program Staff (DS1 & DS2). DS1 and DS2 stated when R1 had arrived to the day program, they observed R1 with swollen legs and R1 had expressed pain on his/her legs. DS1 contacted 911 and also called R1’s responsible party to inform him/her R1 was being sent to the hospital. DADM and S1 stated the phone call with Kingdom Hearts Care home staff, S1, was in the afternoon, after R1 was already sent to the hospital. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED . Although it is a fact that S1 did in fact say, “ it was a waste of resources to call 911 and have the client transported to the ER because it is normal for the client to have swollen legs”, based on interviews conducted, Resident R1 was in the care of the day program when 911 was contacted, and the phone call with the Care Home staff S1 was conducted after R1 had already been hospitalized. Page 2 Out of 2. END OF REPORT.