Complaint Investigation Report

The specimen was obtained, returned to Kaiser Hospital, and results received on 3/8/21 with negative result. An LIC624 (serious incident report) was completed an d faxed to licensing on 3/8/21. The physician's office did not respond to facility's request in a timely manner. Although the urinalysis was not completed until 3/9/21, result was negative for a UTI. The delay in testing did not risk R1's health. The allegation stating staff did not report incident as required was investigated and ruled on September 10, 2021, with a substantial findings. A citation was issued on the same day.

According to interviews R1 was apparently running in the community and fell with no injuries. Primary Care physician and POA were notified. No state report was required. Resident was encouraged to walk and not run to move about, there were no falls in the community prior to this one.

Based on records reviewed and interviews conducted by LPA, the allegations were UNSUBSTANTIATED , meaning that although the allegation may have happened or is valid, there is not a preponderance of evident to prove that the alleged violation occurred.

Facility has electronic MARs, (Medication Administration Report). There was no deviation or sign that there was a medication error with vitamin D, on the date given or the month of December 2020 that was pulled up. In addition, the primary care physician discontinued this medication completely on 12/18 2020.

Foot closed on Resident #1 by Resident #2 in December 2020.

There is absolutely no documentation (external or internal) that this even even occurred.

Based on the above, there is insufficient information available to determine if the incident occurred.

The allegations are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evident to prove that the alleged violation occurred.

Per California Code of Regulations, Title 22, no citations were issued.

An exit interview was conducted and a copy of this report was given to Deborah Taylor.