Complaint Investigation Report

During today’s visit, the LPA conducted a physical plant tour at 11:39 a.m., to ensure there are no health and safety hazards.

Regarding the allegation, ‘Facility did not obtain consent from responsible party prior to client undergoing dental procedures,’ the complainant’s concern is that the facility failed to provide services as specified in client #1’s (C1’s) Individual Program Plan (IPP) Progress Report which was approved on 04/29/2021, which required the facility to obtain consent from C1’s responsible party anytime C1 required any type of medical or dental procedure.

During the investigation, the LPA conducted a record review, interviews with the complainant, facility staff, and the administrator. The interview with the complainant revealed that the administrator was aware and was in agreement that before moving forward with any dental treatment, it would be discussed with C1’s family. Interviews with facility staff revealed that the administrator ‘notifies the client’s family’ regarding all medical and dental concerns. An interview with the administrator revealed that the administrator failed to obtain consent from C1’s Responsible Party (RP) prior to C1 undergoing dental procedures. The administrator also revealed that in May of 2021, C1 was taken to their follow up dental appointment where a dental procedure was done without consent of C1’s responsible party; due to the fact that the facility was un aware of additional procedure being conducted during that dental visit. A record review revealed that C1’s responsible party is ‘authorized to make any medical appointments and decisions and provider needs to discuss and get approval before any procedure is done.’

Based on record review, interviews with the complainant, staff, and the administrator, there is sufficient evidence to support the allegation ‘Facility did not obtain consent from responsible party prior to client undergoing dental procedures.’ Therefore, this allegation is deemed Substantiated at this time.

Regarding the allegation, ‘Facility did not report concerns regarding client's health to responsible party,’ the complainant’s concern is that the facility failed to notify C1’s responsible party concern’s regarding C1’s health as specified in their IPP. C1 had a loose tooth, and the dentist informed staff that a bridge would be required when the tooth feel out. However, the responsible party was not informed that two (2) teeth would be removed, and subsequent teeth would be replaced.