Complaint Investigation Report

Between 10:05am – 11:30am, LPA reviewed six (6) residents and three (3) staff members files. LPA also conducted interviews with the Administrator, two (2) staff/Caregivers, and four (4) out of six (6) residents who were able to answer questions.

During today’s visit, LPA requested copies of resident and staff rosters. At approximately 9:20am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. No immediate health and safety issues were identified.

Allegation: Staff did not ensure residents care plan was followed.

The Reporting Party (RP) alleged that staff did not follow the resident’s discharge instructions and did not schedule necessary follow-up care. The investigation included a review of the resident’s admission documents, care plan, discharge paperwork, and any available documentation related to follow-up appointments or coordination of care. LPA reviewed facility records to determine what actions were taken by staff to implement the resident’s care plan and discharge instructions. During the investigation, the LPA learned that the resident’s wife maintained full control over the resident’s medical appointments and care-related decisions. Interviews and documentation confirmed that the resident’s wife received the initial hospital discharge papers and informed the facility that she would personally schedule all necessary follow-up appointments. Records did not indicate that the facility was responsible for arranging these appointments once the wife assumed that responsibility. The LPA conducted interviews with the administrator, staff, and residents. Staff reported that they followed the resident’s care plan and discharge instructions to the extent applicable and stated that they deferred to the resident’s wife for follow-up scheduling per her request. Staff denied failing to implement required care plan components. Documentation reviewed did not show evidence that staff disregarded the resident’s care plan or failed to act on discharge instructions. Interviews and records indicated that any delays in follow-up scheduling were related to routine coordination processes or the resident’s wife’s control over appointment scheduling, rather than staff non-compliance. Information obtained during the investigation did not provide sufficient evidence that staff failed to implement the resident’s care plan as required. Records and interviews did not conclusively support that neglect occurred or that the facility failed to follow through with necessary care coordination. Based on the information gathered through interviews and record review, the allegation that staff did not ensure the resident’s care plan was followed is not supported by a preponderance of evidence. Therefore, the allegation is determined to be Unsubstantiated. Continue on LIC9099-C