Complaint Investigation Report

The investigation revealed the following:

In regards to the allegation: “Staff did not meet a client's medical needs while in care.” It is alleged that C1 was ordered to use a CPAP machine and was required to have her blood tested twice daily and prescribed medication to manage diabetes, but the staff has done nothing. (4) out of (4) staff interviewed denied the allegation. S1 indicated that C1's physician recommended a CPAP machine for C1's sleep apnea, but when the doctor attempted to put it on C1 at the hospital, C1 refused. Additionally, S1 stated that the medication to control C1's blood sugar level was discontinued by the doctor due to C1 had severe allergic reaction. As a result, a different strategy was developed, including modifying dietary patterns, and joining a gym to workout. Some staff members interviewed indicated that they knew that C1 needed a CPAP machine but that it was never ordered because C1 wouldn't use it. Some staff interviewed indicated that despite encouraging C1 to use a CPAP machine for her well being, C1 had a strong will and continued to refuse. LPA attempted to contact the Service Coordinator at the Regional Center but was unsuccessful due to no response received. LPA also attempted to interview (4) clients who lived with C1, but unsuccessful due to their cognitive abilities. Therefore, there was insufficient evidence to corroborate with this allegation.

In regards to the allegation: “Staff did not address a client's change in vision while in care.” It is alleged that in April 2023, it was discussed that C1 needed to get her eyeglasses, which was delayed and never followed through. (4) out of (4) staff interviewed denied the allegation. Some staff interviewed stated that they are aware that C1 had an eye exam but there were no issues and no order for eyeglasses. Some staff interviewed indicated that C1 enjoyed watching TV and staff did not observe any changes in C1's vision that would raise concerns. LPA reviewed the optical prescription (dated 01/08/2025) and revealed that there was no eyeglass prescription had been found for C1. LPA attempted to contact the Service Coordinator at the Regional Center but was unsuccessful due to no response received. LPA also attempted to interview (4) clients who lived with C1, but unsuccessful due to their cognitive abilities. Therefore, there was insufficient evidence to corroborate with this allegation.