Complaint Investigation Report

Allegation: Staff failed to seek medical attention for a UTI and dehydration. Substantiated

Staff reported R1 had changes in condition beginning in November 2023. They observed R1’s urine was dark in color and had an odor consistent with a urinary tract infection (UTI). Medical records show R1 was seen at the emergency room on 11/17/2023 for a chief complaint of lethargy. However, medical records show not show a urinalysis test was conducted or that they were ever treated for a UTI. Medical records from this visit show R1 was assessed for behavioral issues and their medications were adjusted. On 12/18/2023, staff began noticing a decline in R1’s condition which included changes in weakness and mobility. Staff contacted R1’s family recommending R1 be places on hospice care. The file review records indicate R1’s primary care physician was not contacted regarding R1’s signs of weakness until 12/24/2023. On 12/24/2023, a fax correspondence was sent to R1’s primary care physician indicating R1 was lethargic, sedentary, and no longer able to feed themselves. The physician did not acknowledge receipt of the correspondence. Multiple staff considered R1’s changes in condition to be drastic and warranted her being sent out to the hospital on 12/24/2023. Staff reported R1 was sent out to the hospital on 12/24/2023. However, medical records support R1 was not sent out to the hospital until 12/25/2023 at approximately 1600 hours.

As a result of this investigation, LPA finds the allegation to be Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted. A copy of this report was left with the facility.