Complaint Investigation Report

AP1 advised that antipsychotic medications require medical evaluation "to rule out a medical problem, such as UTI or urinary retention." AP1 explained to licensee that UTI and urinary retention contribute to increased behaviors. Per AP1's interview and medical notes, licensee stated to AP1 on July 24, 2020 that R1 had hit a nurse and an incident report was submitted to CCLD (unknown date). No such incident report was submitted to CCLD. AP1 ordered the resident to be seen on July 24, 2020 but the client was not brought to the VA to be evaluated. This was corroborated by interviews with AP1 and Licensee.

On July 27, 2020 R1 was brought into to be seen and AP1 determined that R1 was retaining 600 cc of urine even though the resident was able to release some urine. According to AP1, anything more than 100 cc of urine is urinary retention and requires additional medical attention. AP1 ordered the Licensee to bring R1 to the ER with a recommendation of a bladder scan for the urinary retention and insertion of a foley catheter. In the interim, to rule out untreated UTI, per medical procedure according to the VA's Licensed Medical Social Worker, AP1, and AP2, that antibiotics were prescribed. AP2 during an interview on August 14, 2020, stated that the benefits of prescribing antibiotics for the UTI far outweighs untreated UTI. Any side effects from the antibiotics would not be as significant as an untreated UTI and that it would be overseen by the physician. Medical records: Resident complained of suprapubic pain for one week. This was noted by AP1 in the VA report.

July 28, 2020 Licensee was asked to come back into the office because the VA found out that they had an ultrasound machine, as well as, lab results for the urinary analysis. Lab results returned negative for a UTI but that R1 still had 600 cc of urine. AP1 ordered that the resident be taken to the ER that night. Per Licensee's interview, the resident refused to be brought to the hospital for a foley catheter, therefore, Licensee did not take R1 to the hospital. On July 29, 2020 Resident was brought to the ER for a foley catheter insertion.

During interview on August 18, 2020 with the Licensee denied that a physical or violent incident occurred. Licensee denied there was an incident that occurred regarding resident hitting staff. AP1 suspected that Licensee was lying to manipulate AP1 into ordering a medication increase. Based on LPA's interview with the Licensee, Licensee was inconsistent regarding the physical incident that R1 apparently hit a nurse. Licensee admitted that he "presented symptoms to the doctor to see what we can get for R1" to address the behaviors."