Complaint Investigation Report

Allegation: Staff refused to allow resident’s hospice agency to provide care to resident as ordered by a physician

Based on records review, Admission Agreement indicates Resident #1 (R1) was admitted to the facility on 12/29/2022. A hospice referral for R1 from SCAN Health Plan with Healing Care Hospice was dated 12/30/2022.

It was alleged that staff refused to allow resident’s hospice agency to provide care to resident as ordered by a physician. On 1/9/2023 from 11:00 am – 1:55 pm, LPA Lourdes Montoya conducted interviews with four out of four staff (S1-S4). LPA attempted to interview five out of five residents (R2-R6). Two out of five residents were sleeping, two out of five residents refused the interview, and one out of five residents was unable to maintain a conversation. R1 was transferred to another facility and LPA was unable to obtain statements from R1 during the visit.

Interviews with six witnesses (W1-W6) disclosed that Healing Care Hospice agency was the selected and preferred hospice agency to provide hospice care services to R1. Two out of six witnesses revealed the visiting nurse from Healing Care Hospice agency attempted to visit and assess R1 on 12/30/2022 around 6:00 pm, but facility staff denied the nurse an entry to the facility. W5 revealed R1 was transferred to another facility on 1/5/2023 due to the facility’s refusal to use R1’s preferred and contracted hospice agency.

Based on interviews conducted, two out of four staff (S3-S4) claimed they were confused about who is supposed to provide hospice care to R1. Both staff stated Global Hospice delivered a hospital bed, comfort kit, oxygen tank, and bedside table to the facility for R1 but another hospice agency (Healing Care Hospice agency) attempted to assess R1 on 12/30/2022 and the hospice nurse was denied entry. Two out of four staff (S1-S2) claimed there was no doctor’s referral for Healing Hospice Care agency to provide hospice care to R1. They also claimed Healing Care Hospice Nurse was not denied entry on 12/30/22 instead the visit was only placed on hold due to a confusion which hospice agency, between Global Hospice and Healing Care Hospice, was selected by R1’s family.