Complaint Investigation Report

Allegation: Staff abandoned client at hospital.

The details of the complaint reported client #1 (C1) was refused by staff to return to this facility. (C1) was admitted to St. Mary's Medical Center on 02/11/23 due to congestive heart failure. (C1) received medical attention and physical therapy (PT) while in care at the hospital and now is available for discharge. According to a witness #1 (W1), (C1) is ready to be discharged and was refused by the administrator staff #1 (S1) who cannot accept (C1) back at this facility as they have given (C1)'s bed away and that Social Security did not pay for his services. while (C1) in hospital for over 30-days. (W1) claimed that (C1) has maintained continuous physical therapy and is now considered ambulatory. Medical records stated (C1) is back at baseline and considered ambulatory and can walk 150 feet without a walker. An interview with administrators staff #1-#2 (S1-S2) reported that (C1) was admitted to the hospital due to an unwitnessed fall on 02/11/23 and not congestive heart failure. Due to the fall, (C1) suffered swollen and a wounded feet. On 03/15/23, staff #3 (S3) received a call from the hospital who stated (C1) is not ambulating and refusing to cooperate with (PT) and is still using a walker. The hospital was informed that (C1) is unable to return unless (C1) has fully recovered and is ambulatory. (S1-S2) claimed a follow-up call was received from the hospital on 03/16/23 that (C1) cannot fully ambulate. (S1) claimed she made the decision not to accept (C1) back at this facility due to the severity of deteriorating health conditions. (S1-S2) claimed that based on not being able to ambulate and non-complainant with medical medications, and refusing to seek medical attention for a physical and mental condition, the administrators ultimately decided that (C1) require a higher level of care without a written hospital discharge medical assessment. The Department obtained a copy of (C1)’s medical discharge assessment and it stated, “Patient has been calmer for the past couple of days, following commands, more compliant with medications, behaving well.” “Patient is medically stable and cleared for discharge.” There was no indication that (C1) required a higher level of care and must be transferred to a skilled nursing facility.

Based on interviews, observations, and supporting documentation, the facility failed to adhere to Title 22 Regulations Section 80068.5 Eviction Procedures and failed to perform a Needs Services Plan which the client's needs cannot be met by the facility and the client has been allowed to relocate. The preponderance of evidence standard has been met; therefore, the allegation of: " Staff abandoned client at hospita l" is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.