Complaint Investigation Report

Facility not communicating with responsible parties about transportation issues

It was alleged that the bus/van that was used for resident transportation to doctor’s appointments was unavailable for a period of time and this was not properly communicated to residents or their responsible parties. Due to this, R1 reportedly missed medical appointments.

LPA interviewed ED, who disagreed with the allegation. ED stated, “We (facility staff) transported (R1) to everything” and "There may have been an instance when concierge did not receive 48-hour notice to have (R1’s) appointment added to the calendar."

LPA interviewed three (3) additional staff members who all stated they were unaware if families were notified about transportation changes. S5 stated the facility bus was out of commission for a period time for repairs and to be re-wrapped when the facility underwent a change of ownership. S5 stated that although they could not be certain if residents and families were informed of the change, S5 claimed the facility’s communication to families had historically been subpar.

Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED.

Facility charging for services not being rendered

It was alleged that the facility was charging R1 and their responsible party (RP) for services that were not being provided. It was alleged R1 was being charged for the medication management of 14 medications, while only actually taking “five or six.” Additionally, R1 was being charged for housekeeping services that were believed to not be provided regularly as it was reported that the family was cleaning feces in R1’s bathroom. Specifically, the allegations allege that the resident was being charged for level 5

LPA reviewed the residents’ initial Care Plan and reassessments. R1s most recent care plan before their move out indicated the resident was receiving Level 4 care. Additionally, there were 13 medications listed on the residents’ Care Plan, which included four (4) PRN (as needed) medications. LPA reviewed Medication Administration Records (MARs) which confirmed the resident was being provided with the additional nine (9) medications daily. Regarding housekeeping, the resident’s most recent care plan indicated that housekeeping was scheduled to perform cleaning duties once a week.