Complaint Investigation Report

On 5/03/2024, LPA conducted an initial visit where they conducted interviews and record review. LPA reviewed R1’s Admissions Agreement, which indicated that R1 was admitted to the facility as an independent resident on 1/10/2018. LPA also reviewed physician reports, including a previous report from 12/6/2017 that stated R1 was fully independent, as well as a report dated 3/27/2024, which showed R1 had been diagnosed with dementia and experienced confusion and memory loss.

During the investigation, LPA observed that R1 was initially in charge of their own affairs and had an emergency contact listed. However, through interview with previous ED and review of email correspondences LPA found that as concerns regarding R1’s cognitive decline arose, the previous ED contacted the emergency contact (W2) and R1’s Financial Advisor (W3) for guidance on 3/4/2024. The previous ED explained that, based on their observations of R1’s deteriorating condition, they reached out to W3 who is R1's financial advisor to express concerns about R1’s cognitive abilities and the potential risks to R1’s well-being. Previous ED was advised to contact R1’s attorney (W4) for POA information but previous ED never was able to reach W4 before they found out about the new POA. In the time while previous ED was trying to get in contact with W4, W2 took R1 to get a new physicians report. The previous ED stated that they followed the chain of contact, as outlined in R1's original documents, which specified the first emergency contact in case of concern. LPA reviewed and confirmed that based on R1’s emergency contact sheet the previous ED contacted the appropriate person. According to the original Emergency contact sheet W2 was designated as first person to be contacted for R1. The updated Emergency Contact sheet from 3/13/2024 still had W2 listed as the first point of contact for R1.