Complaint Investigation Report

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 2 interviews (S1 – S2), Interview Resident#1-4 (R1 – R4), Interview with R1’s Responsible Party (RP), Interview with R1’s family, Interview with Montclair Hospital Social Worker (SW), Interview with VNA Care Nurse Liaison, copies of resident#1 (R1) Physician’s report dated 09/04/2024, Preplacement Appraisal Information dated 02/06/2025, Claremont Hacienda Observation notes from 01/15/2025 through 02/05/2025, Unusual Incident/Injury Reports from 01/28/2025 through 01/31/2025, Hospice Care Plan, Montclair Hospital Intake Summary, Consult Orders & Discharge Summary, and physical plant tour.

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 01/31/2025, 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 02/01/2025. 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 02/01/2025, R1’s attending physician documented R1 had multiple falls prior to 02/01/2025 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 reappraisal on R1 before accepting them back into the facility. During the interview with the facility administrator, he stated he informed R1’s family members that a reappraisal was needed prior to the resident’s return to the facility. He also indicated a concern for readmitting R1 back to the facility since R1 had three falls in the past weeks prior to this last fall requiring hospitalization. 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 02/01/2025. SW revealed R1’s family was distressed due to the urgency to find new placement for R1 in such short notice. Interview of VNA Care Nurse Liaison revealed R1 was accepted into hospice care on 02/04/2025 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. The VNA Nurse also stated the family did not want R1 to go to a Skilled Nursing Facility, therefore, the doctor ordered hospice for R1. The facility completed the reappraisal on 2/6/25, was informed the resident would be placed on hospice requiring 24-hour nursing care and ultimately accepted R1 back to the facility on 2/8/25.

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