Complaint Investigation Report

In-service training, Training on Reporting Dependent Adult and Elder Abuse, and hospital admission and discharge records.

Allegation: Staff did not ensure that the client was picked up from the hospital.

The department interviewed Staff 1-2 (S1-S2), who reported that the client moved into the facility on 10/22/24. The client signed out that same day at 2:01 P.M. and checked into the hospital. S1-S2 explained that clients have personal rights and can sign themselves in and out. On 10/23/24, S1 went to Los Angeles General Medical Center to pick up the client after discharge. S1-S2 stated that on 10/24/24, the client signed out at 8:40 A.M., returned to the hospital, and was later picked up by staff. On 10/25/24, the client signed out at 3:50 P.M. and checked back into the hospital; S1-S2 stated staff picked up the client again.

S2 described the client as high-functioning and noted that the client is on a 21-day respite placement, and intended to stay at the facility for a limited time. S1-S2 reported that the client frequently calls 911 and checks in and out of the hospital. When the hospital calls to discharge the client, staff immediately go to pick the client up. S1-S2 noted that the client experiences severe seizures, and once released by a doctor to return to the facility, staff retrieve the client. S1-S2 also stated that the client has a cellphone and always informs staff of their location and whereabouts. S1-S2 denied the allegation. During the interview, Client 1 (C1) called staff via telephone, allowing the department to interview C1, who stated that staff always picked the client up from the hospital. C1 denied the allegation. The department attempted to interview Client 2 (C2), who is non-verbal and could only respond with limited words, such as ‘yes’ or ‘no,' and was unable to answer any of the questions. Client 3 (C3) was at the day program and unavailable for an interview.

The investigation revealed the following:

The department interviewed staff members 1-2 (S1-S2), as well as client 1 (C1) who confirmed that staff picked up the client from the hospital each time the client was discharged. S1-S2 and C1 stated that the client had not been abused by the facility staff. S1-S2 stated the client has a conservator. The client returned to the hospital on 10/24/2024 after signing out from the facility. The client was not at the hospital the entire time after staff picked the client up on 10/23/24. S1-S2 stated that the staff does return the hospital's calls. S1-S2 stated the facility is following Title 22 Regulations. S1-S2 and C1 denied the allegation.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated. There were no deficiencies cited. An exit interview conducted