Complaint Investigation Report

The investigation revealed the following: Regarding allegation: Facility did not notify appropriate doctor of resident’s change in condition. It is alleged incorrect doctor was notified of resident’s change in condition. Record review revealed that upon R1’s return to the facility on 6/3/22 family representative notified facility of change of physician. The change was noted in the facility’s face sheet under resident’s contacts – medical, previous physician was crossed out and new physician was written in ink with contact phone number. On 6/7/22 facility staff notified a different physician of change in condition per records reviewed. The physician notified was not previous or R1’s current physician. Per interviews conducted with staff, physician notified is not under the same medical group as R1’s physician at the time. Staff also stated that any changes are noted in the hard copy file as well as the facility’s digital database. The facility staff that notified the physician does not recall the incident. However, per records reviewed the staff made a mistake and notified the wrong physician. Notes revealed physician who was notified, then contacted the correct physician of R1’s change in condition.

Based on LPAs interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Robert and a copy of this report, LIC 9099D, and appeal rights were provided.