Complaint Investigation Report

On 05/28/2024, from approximately 12:30 pm to 2:45 p.m., Investigator Ferris conducted interviews with residents, caregiver, Resident #2’s (R2’s) resident representative, and Assistant Administrator; on 06/03/2024, at approximately 1:30 p.m., with R1’s resident representative; on 06/10/2024, from approximately 9:45 a.m. to 1:00 p.m., with Catered Manor Nursing Center Administrator, Social Worker, and Case Manager, with Vanalden Villa staff, and R1’s resident representatives: and on 06/17/2024, at approximately 1:00 p.m., with DaVita Warner Center Dialysis Center Administrative Assistant. In addition, the investigator reviewed Valley Presbyterian Hospital medical records, Catered Manor Nursing Center medical reports, and death certificate for R1. There was not a complete resident file for R1 available to review and the licensee was cited on a separate report during the initial complaint visit on 04/17/2024.

According to the information provided by the facility caregiver and assistant administrator, R1 was placed at the facility on 04/10/2024 and they were not provided with any documents or information concerning R1. They were aware R1 needed dialysis three times per week, but stated there were issues with the transportation company and R1 did not receive dialysis while in the facility. On 04/13/2024, R1 was taken to the hospital.

Interviews with the DaVita Warner Center Dialysis Center revealed the board & care facility did not arrange transportation and Warner Center Dialysis Center was not responsible for arranging the patient’s (R1’s) transportation to dialysis. In addition, information provided by the Catered Manor Nursing Center Social Worker revealed R1’s insurance authorization for transport was completed and the assisted living facility was responsible to make arrangements with the transport company for R1’s dialysis appointments.

The review of the Valley Presbyterian Hospital medical records revealed R1 was admitted to the Emergency Room (ER) on 04/13/2024 at 11:22am. The patient notes indicated R1 was brought in by ambulance for fever, weakness, and missed dialysis. R1’s medical history included alcohol abuse, end-stage renal disease on hemodialysis, and hypertension.