Complaint Investigation Report

Per record review, R1’s admission agreement, dated and signed 01/02/2020 stated that resident requires or desires assistance in meeting medical and dental needs. Interview conducted with the Administrator from another complaint relating to R1, dated 03/04/2022 stated that R1 went to doctor’s appointments by themselves and R1 did not communicate with facility staff regarding R1’s doctor’s appointments or aftercare. Administrator stated that R1 was independent and dealt with medical care by themselves. However, it was revealed during a record review that R1 had a California Advance Health Care Directive and a Power of Attorney (POA) and in the document R1 stated that R1 wants R1’s agent to make health care decisions now even though R1 currently had the mental capacity to make own health care decisions; document signed and dated 02/25/2016. Interview conducted with the Administrator from another complaint relating to R1, dated 03/04/2022 stated that the facility did not have a copy of R1’s POA paperwork stating that R1 had a medical POA. Additionally, R1 was enrolled in the Assisted Living Waiver Program (ALW) and it was documented on R1’s Individual Service Plan (ISP) dated 06/26/2020 that R1 does not understand all medical appointment necessary to manage R1’s multiple medical diagnoses. The ISP continues stating, “Under medical supervision, participant’s active diagnosis will remain under control with no disease progression. RCFE and participant will work together to identify all medical specialists required to address all active diagnoses. RCFE will assist participant with scheduling all follow up appointments and lab work ordered by MD.” Although facility staff believed R1 was independent and was capable of caring for R1’s own medical care, R1 did need assistance with arranging medical care and the facility staff should have communicated with R1’s POA/ responsible person regarding R1’s medical care and needs. Furthermore, facility staff should have maintained proper paperwork that was essential to observing R1 and ensuring that R1’s medical needs would be met. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are deemed Substantiated.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.