Complaint Investigation Report

LPA reviewed the centrally stored medication and destruction record and did not observe any discrepancies.

Allegation: Client has lost a lot of weight while in care.

Based on review of weight record from C1’s admission until January 2024, the record indicated C1 had continued weight loss. W1 stated that the weight loss was rapid but now is at a slow pace. S1 stated C1’s primary physician did not have a problem with the weight loss. The Department reviewed two (2) after summary visits that addressed C1’s weight loss and on January 16/2024, there was an issue that was addressed that could cause the weight loss; however, it was not fault of the facility.

Allegation: Client has fallen multiple times and sustained bruising while in care.

Based on interviews and review of incident reports it indicated C1 had fallen and sustained bruising multiple times. W1 stated during interview that most of C1’s falls occurs when C1 visit home on the weekends, and that possibly the falls are due to the dosage of medication. S1 stated during interview body checks are done and noted when C1 returns home from visit. S1 also stated that C1’s gait evaluation from Contra Costa Health that was conducted on August 31, 2023, shows instability which causes C1 to fall. Further record review from indicated a diagnosis that causes C1’s falls.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.