Complaint Investigation Report

Allegation: Facility staff interfered with resident's right to receive medical care.

According to interviews with the Administrator and R1’s responsible party, R1 had a dialysis appointment scheduled 2/8/24. Interviews indicated that R1 goes to dialysis three times per week. Interviews indicated that R1 did not make their appointment on 2/8/24. Interview with the Administrator indicated that R1 did not make their dialysis appointment due to the road being blocked by SMUD for repairs to a power line. Administrator also stated that Regional Transit (RT) was unable to pick up R1 for the appointment due to SMUD blocking the roadway. Interview with SMUD indicated that they were conducting work on a broken pole from 2/4/24-2/8/24 and that tree work was involved as well. SMUD indicated that they have no record of the road being blocked or closed. According to documentation obtained from RT, a driver arrived at the care home on 2/8/24 at 9:49am to pick up R1 and take them to their dialysis appointment. Documentation indicated that the RT driver went to the facility door and was advised by facility staff that R1 was eating and needed more time. The RT driver attempted to call the facility phone and it went straight to voicemail. The RT driver attempted to contact the facility an additional time and left a voice message. Documentation indicated that the RT driver departed the facility at 9:56am. RT notes indicated that staff from the facility kept calling to rebook the trip and, when informed RT could not, staff would hang up. RT noted that they attempted to ask the facility staff if R1 still needed a return trip transport from the dialysis appointment and staff would hang up with no response. Documentation indicated that an RT driver arrived to pick up R1 from their dialysis appointment at 2:42pm, however, R1 was not at the appointment location for pick up. RT staff indicated that R1 has set appointments with RT for transport to and from their dialysis appointments three times per week. Administrator stated that the 2/8/24 dialysis appointment is the only one R1 missed.

Based on medication counts, records reviewed, and interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.