Complaint Investigation Report

Allegation: Staff did not update resident's medical records.

The department conducted extensive interviews regarding the allegation cited above. An interview conducted with the reporting party revealed that R1 has been switched from Kaiser Permanente to Mercy Health effective January 1, 2025, which the facility was notified and provided with an updated medical card. An interview conducted with the Health and Wellness Director on March 7, 2025, revealed that the resident (R1) was sent out to Kaiser Permanente Roseville for evaluation due to leg pain. The Health and Wellness Director stated a new medical card was provided; however, it was not updated on the chart, therefore, R1 was sent to the wrong medical facility for evaluation. Based on R1’s identification and emergency information, it revealed that R1’s hospital to be taken in an emergency was previously written as “Kaiser Roseville” and then crossed out with new input of “Mercy Folsom”. File review of hospital discharge paperwork and progress notes revealed that R1 was sent out to Kaiser Roseville for evaluation.

Based on the information obtained, the allegation is 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, copy of report and appeal rights was provided.