Complaint Investigation Report

Staff did not seek medical attention in a timely manner.

It was alleged that staff did not seek medical attention for a resident, R1, in a timely matter, resulting in R1 being hospitalized. A friend of R1 (F1) had arrived at the facility to visit with R1. When FF entered R1’s apartment, FF observed R1 to be in bed, non-verbal, and staring at the wall. FF described R1 as being in a “catatonic” state. FF stated they contacted a staff member who stated they would be in shortly to assist. FF claimed that approximately 20 minutes passed and no staff arrived. FF called R1’s responsible party (RP), and informed RP of the situation. RP then arrived at the facility and observed R1 to be in the same state. Emergency Medical Services were called and R1 was taken to the hospital. R1 was out of the facility for approximately two weeks at the hospital and a skilled nursing facility before returning to the memory care facility.

LPA interviewed four (4) staff members regarding the circumstances of the allegation. Staff #2 (S2) and Staff #3 (S3) both reported similar details of the events. Staff reported the evening before the above allegation occurred, staff observed R1 to not be at their baseline. R1 was breathing and awake but was observed to be slow to respond. Staff followed protocol by informing the Director of Health and Wellness as well as R1’s responsible party (RP). RP reportedly did not want R1 sent out to the hospital and requested the facility stop administering a recently prescribed medication. The facility followed RP’s wishes by not calling EMS at that time and reportedly faxed R1’s Primary Care Physician (PCP) with the previously mentioned information. However, the PCP would not be returning to the office the following Tuesday, five days later. LPA reviewed the facility care notes documented for R1 and found a care note describing the same information on August 28, 2025, at 6:13 pm.

S2 stated the next day, August 29, 2025, S2 reported to R1s room to check on them and discovered them in the previously mentioned “catatonic state.” S2 stated they consulted with the RP at that time, and it was S2 who called Emergency Medical Services (EMS). S2 noted they arrived at R1s room within a few minutes of the RP arriving and was not aware of who R1’s friend had informed spoke too. No other staff interviewed had any knowledge of R1’s visitor being present other than the RP.

LPA reviewed R1’s care notes and discovered a care note that was input at 10:15 am on August 29, 2025, explaining the previously mentioned information. It was noted that EMS was called at approximately 8:30 am.

Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED. Exit interview conducted. A copy of this report was forwarded to Executive Director, Ilona Corpus.