Complaint Investigation Report

The investigation revealed the following. Regarding Allegation : Staff did not accept resident back into care following hospitalization- It is alleged the facility refused to accept R1 back into the facility after R1 had a fall and was ready to be discharged by the hospital back to the facility. Review of R1’s facility record revealed, R1 was admitted into the facility on 12/03/2023. Review of Unusual Incident/Injury Report dated 1/31/2025, revealed R1 was found by staff, lying on their left side, with their head touching the bathroom floor. Staff called 911 and R1 was transported to Montclair Hospital. Facility staff notified R1’s primary care physician and responsible party. Interviews with R1’s family revealed R1 was ready to be discharged on 2/1/25 and family tried multiple times to get R1 back into the facility. R1’s family revealed facility staff refused to accept R1 back into the facility due to R1 having multiple falls and being a fall risk. During records review, LPA Ramirez reviewed R1’s hospital records. R1’s hospital records revealed on 2/1/25, R1’s attending physician documented R1 had multiple falls prior to 2/1/25 and now R1’s assisted living facility (ALF) is unable to accommodate for R1’s care. Two (2) out of the two (2) staff interviewed denied this allegation. Staff interviews revealed staff did not refuse to accept R1 back into the facility, however, staff needed to conduct a reassessment on R1 before accepting them back into the facility. LPA Ramirez reviewed R1’s reassessment conducted by the facility on 2/6/2025. Interviews with Montclair Hospital Social Worker (SW) revealed they began looking for new placement for R1 due to the facility refusing to accept R1 back into the facility after 2/1/25. SW revealed R1’s family was distressed due to the urgency to find new placement for R1 in such short notice. SW revealed R1 did not require skilled nursing care and R1 was placed on hospice care on 2/4/25. Interview of VNA Care Nurse Liaison revealed R1 was accepted into hospice care on 2/4/2025 and R1’s family has been in contact with VNA trying to find another board and care facility for R1 since R1’s facility was refusing to take R1 back because they were a fall risk. On 2/8/2025, facility staff accepted R1 back into the facility. Although the staff accepted R1 back into the facility on 2/8/2025, staff allowed 6 days to pass before arranging or assisting in arranging R1 with incidental medical care, back into the facility.

Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . LPA Ramirez will issue a Type A violation based on this investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided via email.