Complaint Investigation Report

Per R1's records, R1 was admitted to the hospital on 8/28/2023 with a chief complaint of generalized weakness and Urinary Tract Infection (UTI). Records state that R1 reported to have abdominal pain and poor oral intake for the past three days prior to admission. On 9/3/2023, R1 was discharged from the hospital with a UTI and generalized weakness. Interview with R1's responsible party (RP) indicated that R1 moved to the facility on 7/8/2023 and was able to use their walker, go to the bathroom, and communicate with others in the home. RP stated that they noticed R1 getting weaker and having a harder time communicating. Interview with staff (S1) indicated that they noticed R1 getting weaker while working with R1. S1 stated that they did not notice any signs of a UTI regarding R1, but stated that they were not educated on the signs to look for related to a UTI. Administrator stated that R1 was showing signs of a UTI five days prior to being sent to the hospital on 8/28/2023. Follow-up interview with Administrator indicated that they noticed a change in condition with R1 five days prior to them being sent to the hospital on 8/28/2023, but did not suspect R1 having a UTI until three days prior to R1 being sent to the hospital on 8/28/2023. Administrator stated that the signs were not severe or urgent.

RP and Administrator attempted to get a hold of R1's doctor to obtain an order for a urine sample. Administrator stated that R1 was showing signs of weakness and confusion, and R1's urine had an odor. It was not until 8/28/2023 that R1 was declining to eat meals. Administrator stated that once R1 stopped eating and missed two meals, Administrator called 911 and sent R1 to the hospital. Administrator indicated that R1 had prostate cancer and, therefore, had frequent UTIs. Administrator stated that R1 did not sustain a UTI due to anything done by the facility.

Per R1’s Physician’s Report dated 7/6/2023, R1 was diagnosed with Dementia. R1’s records also indicated that R1 had prostate cancer and bowel and bladder impairment, requiring assistance with toileting. R1's records indicated that they were able to communicate their needs and ambulate with their walker.

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

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Administrator's signature on these forms acknowledges receipt of these documents.