Complaint Investigation Report

***This page was ammended to change findings from Substantiated to Needs Further Investigation. For final findings, see report delivered on 03/11/2023***

Information received revealed that R1 was admitted to the facility on 11/14/2020 upon discharge from the Kaiser Hospital. Upon arrival, R1 was covered in bruises all over their body. The Administrator took pictures of R1 bruises. The Administrator verified that they had knowledge of R1’s multiple health problems requiring close supervision. Further interviews revealed that R1 was retained in the facility between 11/14/2020 to 11/23/2020. Facility staff assisted R1 with incontinence care and never saw any redness or rashes on R1’s body. On 11/23/2020, staff attended to the resident and found R1 unresponsive. 911 was called and R1 was transferred to the hospital. A review of Hospital records revealed that R1 was admitted to the hospital on 11/12/2020 and discharged on 11/13/2020. R1 had multiple health problems requiring close supervision and frequent attendance. R1 was readmitted to the hospital on 11/23/2020 due to being unresponsive. The information revealed from medical records verified the information received from interviews. Overall interviews of facility staff and review of facility records does not reveal any relevant information to conclude that R1’s care and supervision was neglected at the facility. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

During complaint investigation LPA noted other Title 22 deficiencies unrelated to the complaint. The deficiencies were addressed during case management visits conducted on 02/11/2022 and 01/31/2023.

Exit interview was conducted and copy of report was issued.