Complaint Investigation Report

(PAGE 2) REPORT CONTINUED FROM LIC 9099...

On 3/10/2025, the Department received a complaint regarding the following allegations, Staff provided client extra fluid without a physician's order and Staff did not ensure client records were complete. LPA and staff toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations.

During today’s visit, at 12:14 p.m. LPA conducted a physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations, at 12:36 p.m. conducted a file review and obtained copies of pertinent documents relevant to the investigation.

On the allegation Staff provided client extra fluid without a physician's order, it is the concern of the Reporting Party (RP) that the facility staff, Staff #1 (S1) provided Client #1 (C1) with extra fluids without a physician’s order. To investigate this complaint, LPA reviewed the facilities protocols, policies, procedures, and orders as they pertain to physician's orders and conducted a file review for C1. Review of the facilities protocols, policies, procedures, and orders as they pertain to physician's orders revealed that “Policy #600 Nutrition and Hydration Policy and Procedures. V-Encouraging and Restricting Fluid. Nursing must verify that there are physician orders for a particular procedure and follow the health care plan to assess any special needs. Only orders prescribed by the doctor can be executed. All correspondence with the physician must be documented and during endorsements must be reviewed with next shift.” File review for C1 revealed that S1 failed to adhere to the physician’s order and provided C1 with more than what was prescribed. On 10/01/2024 S1 provided extra fluid for urine output. This was never prescribed by the doctor. Based on information obtained, reviewed, file review and a credible witness there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff provided client extra fluid without a physician's order is deemed substantiated at this time.