Complaint Investigation Report

a written or electronic prescription for C1’s new medication. At 1145pm, the Administrator contacted the hospital regarding the new medications; in which he was told the prescribing physician, or the hospital Case Worker was not there, and they would contact the Administrator in the morning. At 8am on 10/11/2021, the Administrator re-contacted the hospital again, and left another message for a returned phone call; whom the hospital did not return the phone call to the Administrator. Shortly after, the Administrator contacted, and faxed C1’s discharge instructions to C1’s primary physician, who reviewed the documents, and instructed the Administrator to continue with the already prescribed medications, and the doctor would reassess C1 for the (2) additional medications. An appointment was scheduled for 10/13/2021. The primary physician only ordered (1) of the new medications, and the other was not needed. Although, C1 was prescribed (2) new medications upon discharge, the hospital did not provide a written prescription, and the Administrator followed discharge orders by contacting the primary physician, who instructed the Administrator to continue the medication for C1, until the re-assessment appointment could be scheduled. Therefore, based on documentation and information obtained, there is insufficient evidence to prove, ‘Staff mismanaged client’s medication, and the allegation is UNSUBSTANTIATED at this time.

Allegation # 2: Staff are not meeting client’s medical needs: On 10/20/2021 and 10/21/2021 from various times, ranging from 8am to 1pm, LPA conducted interviews, reviewed facility file documents, and client records. On 10/10/2021, client #1 (C1) was discharged from the hospital and relocated to the Administrator’s CCL (Community Care Licensing) facility. Record review and interviews conducted, revealed C1 resided in the other licensed facility owned by the Administrator for (23) years, that is regulated with the Department of Public Health, as a ICF – DDH (Intermediate Care Facility – Developmentally Disabled – Habilitative). Prior to C1’s discharge from the hospital, it was reported to LPA there was a discussion with Regional Center, family and the Administrator, who agreed upon having C1 relocate to the CCL facility, due to the facility having more staffing to handle the needs of the client. LPA was told that the ratio for staffing for the ICF was 1:3, whereas for the CCL facility, it was 1:2, and due to the Administrator’s medical credentials and the staffing for C1’s medical needs, it was determined to be an appropriate level of care at time of discharge. LPA was also informed that medical equipment for C1, was delivered on 10/08/2021