Complaint Investigation Report

Regarding the allegation “Staff did not notice a change in resident's condition.” It was alleged that R#3 resident loss 35LBs of weight within 30 days. Staff interviews revealed the following: Five (5) out of Five (5) staff denied the allegations, Staff 1-5 (S#1-#5) denied “Staff did not notice a change in resident's condition.” Interviews with staff S#1-S#5 revealed that the reason R#3 had lost weight was not due to diet, but R#3 was reported to have had experienced depression symptoms 6-7 weeks before entering the facility, which had intensified. S#1-S#5 corroborated that R#3 stopped taking drugs about a year ago. S#1 stated sometimes R#3 was not hungry and S#1-S#5 stated they could not force feed R#3—some days R#3 would eats all the food at the facility that was provided to R#3. S#1-#5 stated that R#3 would stated they would not want to eat anymore. LPA could not interview R#3 due to discharge on February 3, 2023. There was one client present and discharged on 09/07/2023 at 12:19 PM who did not want to be interviewed. Record reviews indicate the following: the admission date for the R#3 was on January 2, 2023, at 1:00 PM, while the discharge/transition date was on February 3, 2023, at 1:00 PM. A record review of R#3 physician's report showed R#3 had documented weight loss due to ongoing medical conditions.

Regarding the allegation “Staff did not seek medical attention for resident in care.” It was alleged that: Staff did not seek medical attention for resident in care which led to the decline in the residents health condition. Staff interviews revealed the following: Five (5) out of Five (5) staff denied the allegation “Staff did not seek medical attention for resident in care.” Per interview with S#1 resident R#3 voluntarily stopped taking his psychiatric medicine, resulting in R#3's current medical condition. LPA could not interview any clients regarding the allegation “Staff did not seek medical attention for resident in care.” There was one client present who was discharged in the afternoon 09/07/2023. LPA could not interview family or clients at the time of visit. Record reviews indicate the following: A review of physician’s report for R#3, Admissions; Ancillary; Diagnosis; Discharge Financial; Nursing; Outcomes; Outpatient; For Review; Billing Flags; Assessment client; Account Details; Collateral; Contact Notes; Daily Client Report; Group Sessions Insurance; LABS Licensing; MARs; Medical Misc/Legal/Correspondence; PHI Log; Physician's Orders; Progress Notes; Staff Forms; Treatment Plans; Lab Orders; Lab Requisitions; * Lab Reports A; Appointments; Chart Summary; and Text messages were completed and found there’s was no evidence to corroborate neglect in care that resulted to staff not seeking medical attention for resident in care or lack of supervision resulting in resident hospitalization. Medical reports confirmed that R#3 attempted suicide at age 63, a second attempt involved self-inflicted neck and wrist lacerations (documented). R#3 was admitted to UC Irvine for two weeks.