Complaint Investigation Report

Allegation: "Neglect/lack of supervision led to hospitalization of client." It is alleged that client (C1) was hospitalized on January 19, 2022 as a result of neglect of health that resulted in a pneumonia diagnosis. Client (C1) has congestive heart failure, which makes the client prone to accumulation of fluid in the lungs. On January 17, 2022 staff called C1's Primary Care Physician (PCP) to report a slight cough. The facility was instructed to administer PRN cough medicine. On January 18, 2022, staff called the PCP because C1's cough persisted. A new cough medicine was prescribed by MD, and staff were instructed to monitor client's blood pressure and oxygen levels. On January 19, 2022, Assistant Administrator called C1's MD because the client did not look well. Per physician's order, staff was instructed to call 911. C1's sister was present and made the 911 call that resulted in C1's hospitalization. In regards to the most recent hospitalization (7/17/2022), client (C1) was staying at it's family's home and began to get ill. Family notified C1's primary physician and 911 was called. C1 tested positive for COVID-19 virus at the hospital. The client was treated for mild pneumonia and discharged 2 days later. Based on record review and interviews conducted the findings indicate staff contacted C1's MD in a timely manner and client received medical care per physician orders.

Allegation: " Facility staff failed to notify authorized representative of client's condition prior to hospitalization. " Based on interviews conducted and record review the findings indicate that client (C1's) authorized representatives were notified of C1's cough and decline in health on January 17, 2022, the day the client developed a cough. All staff stated that C1's authorized representatives are always immediately contacted because they are very involved in the client's care and want to be immediately notified of any changes in condition. Family member (F1) stated that on January 17, 2022 staff called to notify about client's cough, physician instructions; and this information was communicated with other family members. Therefore, this allegation is not supported.