Complaint Investigation Report

Allegation: Unqualified staff accessing resident.

The details for the complaint alleged that an unqualified staff accessed resident #1 (R1) with a mental disorder. The complainant reported (R1) was assessed by a staff working at this facility and used the information to notify the hospice's medical director who accepted the data and diagnosed (R1) with Dementia. According to the complainant, (R1) is not suffering from Dementia and is able to carry out normal activities and engage in meaningful conversations with other residents. This diagnosis is disputed by the complainant for (R1).

The facility’s admission agreement for (R1) indicated on 03/29/22 was accepted for admission after being discharged from a local hospital 04/01/23. The medical discharge report did not indicate an assessment of (R1’s) mental condition. Based on a physician's report dated 03/28/22, (R1) is in fair health with no evidence of mild cognitive impairment or dementia. As a result, (R1) was later admitted under the care of Diamond Hospice Services Inc on 04/03/22 to 11/27/22. (R1) was diagnosed with Senile Degeneration of the Brain by a hospice physician. (R1) continued hospice care with Generations Hospice from 12/10/22 – 06/06/23 and was diagnosed with Alzheimer’s Disease. (R1) was discharged from Wellsprings Manor Senior Care on 06/12/23. (R1) was transferred to The Heavens at Antelope Valley on 06/08/23. A physician report dated 05/27/23 diagnosed with Dementia and resides in memory care. A review of hospice, medical, and service records revealed (R1's) family representatives had acknowledged (R1's) health condition verified with a signature.

An interview hospice representative (W1) stated (R1) was given a Mental Status Examination as (R1) was previously diagnosed by Diamond Hospice with Senility on 04/03/22. (W1) stated it is likely (R1's) condition will change within eight months of switching hospices. (R1) was admitted by Generations Hospice care. Based on the information gathered, the allegation mentioned above cannot be supported.

Allegation: Staff unable to locate resident’s food.

The details for the complaint alleged the staff was unable to provide proper meals to resident # 1 (R1). The complainant reported on 06/11/23 (R1) did not have dinner. (R1) only soup and had leftovers and did not offer a proper meal to (R1). (Evaluation Report continues LIC 9099-C)