Complaint Investigation Report

Interview with the administrator revealed that the ibuprofen was administer because it is a PRN medication that was prescribed to C1 in Septembers 2022 and was also given the approval to administer by the facility's nurse consultant. Interview with the facility's nurse consultant revealed that the administrator was told that the ibuprofen can be administer only if it is prescribed to C1 and if it is a PRN medication. Review of C1's medication records did not list the ibuprofen as a PRN medication. Furthermore, the label on the ibuprofen does not state that it is a PRN medication and instead it states to "take 2-3 tablets by mouth every 6 hours as needed for pain for 2-3 days". The ibuprofen was filled on 09/06/22 and it should have been discontinued 2-3 days from the filled date. Clients were not able to answer questions due to their intellectual capabilities.

Regarding the allegation " staff did not ensure client attended physicians medical appointment ”, it is alleged C1 missed a physician's telephone appointment on 11/23/22 at 9:15am. Interview with the administrator revealed that on 11/22/22 she scheduled the telephone appointment and due to unforeseen circumstances she was not able to be at the facility from 11/23/22 to 11/28/22. However, S1 was at the facility on 11/23/22 to do the telephone appointment with C1. Interview with S1 revealed that the clinic did call and it was from a nurse to conduct a check in and ask for C1's symptoms. S1 was told that the doctor will be calling soon, but according to S1 that call was not received. Interview with the Harbor Community Care Clinic Representative revealed that the first call is a check in call and it is made by the medical assistant. The check in call was answered by the patient, but the 3 calls made after by the doctor were not answered and therefore they considered this appointment a no show. The doctor called the same number that the medical assistant called for the check in. Additionally, C1's family member received a text message that C1 missed this doctor's appointment. Clients were not able to answer questions due to their intellectual capabilities.

Regarding the allegation "staff did not seek medical attention in a timely manner”, it is alleged that on 11/16/2022, C1 began to be sick with a cold and flu like symptoms and was not taken to see a doctor while he was sick. Interview with the administrator revealed that there was no in-person appointments available thus a virtual appointment was done on 11/18/22 through Teladoc and they recommended for C1 to stay home due to C1's symptoms and if C1 did not get better then to follow up with primary doctor. C1 did not get better and thus the 11/23/22 telephone appointment was scheduled. Facility did not take C1 to urgent care. C1's family member received a text message that C1 missed the telephone doctor appointment on 11/23/22 which led to the family member taking C1 to an urgent care on 11/24/22 and C1 was diagnosed with acute bronchitis. Review of urgent care documents dated 11/24/22 confirmed that C1 was diagnosed with acute bronchitis. Clients were not able to answer questions due to their intellectual capabilities. (CONT. TO LIC 9099C)