Complaint Investigation Report

On the allegation ‘Facility did not seek resident timely emergency medical attention’, it is alleged that the facility neglected resident #1 (R1). According to the Reporting Party (RP), the facility did not call for a first responder until the resident had already passed. The resident had abdominal pain for several days; however, medical care was not sought.

To initiate this investigation, on 11/16/21, at approximately 10:35 a.m., the LPA interviewed staff #1 (S1) who stated that R1 had not complained of pain or not feeling well during the week of 11/08/21. S1 stated that they were monitoring the residents for COVID-19 symptoms, such as fever, coughing or other symptoms. R1’s temperature was taken and there was no fever. R1 was staying in their room, including for meals, but S1 could not explain why R1 was isolating themselves.

On 11/16/2021 at approximately 11:10 a.m., the LPA interviewed the administrator about the above allegation. The administrator stated that during the week of 11/08/21, R1’s day program alerted the administrator that R1 was not their ‘usual alert.’ They stated that they would let R1 rest on a bed until it was time to take R1 back to the facility and the nurse would keep R1 under observation. When R1 returned to the facility, R1 was eating as usual and was alert with no symptoms. The facility staff was monitoring R1 for fever, coughing and any other COVID-19 related symptoms. The administrator stated that they called the doctor’s office to make an appointment for R1, but the earliest available appointment was for 11/11/2021 at 10:30 a.m. The administrator stated that they called the day program to inform them of the doctor’s appointment.

On 04/15/2022 at approximately 3:52 p.m., LPA Urena interviewed the Program Director (PD) for the day program attended by R1. LPA Urena asked the PD about R1’s physical demeanor during the week of 11/08/2021, and on the day of 11/09/2021, when R1 was noticed at the day program not to be their ‘usual alert’. The PD explained that R1 was usually talkative, alert and very active, going ‘up and down’ at the day program. However, on 11/09/2021, at around 8:45 a.m. the day program staff noticed that R1 was very quiet and was just sitting down. The PD stated that R1 said they were having stomach discomfort. The ED stated that the R1’s temperature was taken, and it registered at 97.0 degrees. Staff also noticed that the R1 was holding their abdomen where the colostomy bag was located. R1 reported to the staff that they had been in pain since they left the facility in the morning.