Complaint Investigation Report

It was also alleged R1 missed a medical appointment on 02/26/2020. Interview with witness revealed R1 chose not to attend the medical appointment. A review of the Facility Shift Report dated 05/22/2020, the third party transportation company did not pick R1 up for a medical appointment. Facility staff denied R1 required or received emergency treatment for any of the missed medical appointments. However per Facility Shift Report dated 3/2/2020, R1 was sent out due to their wound bleeding excessively and leaking through the gauze. The department was not able to obtain corroborating documents regarding the emergency treatment either from witnesses or other third-parties. Therefore, this allegation is unsubstantiated at this time.

Facility is allowing resident to leave unassisted It was reported that R1 was allowed to leave the facility unassisted when going to their medical appointments. R1 is ambulatory and per their physician’s reported dated 3/26/2020, R1 is unable to leave the facility unassisted. R1 did not have any reported eloping incidences and utilized a third-party transportation company to go to their appointments. An interview with the facility administrator revealed that there was a time when the third-party company was not coming inside to sign the residents out, the resident was not leaving unattended, as there was facility staff present in the lobby. This matter was addressed per the facility Administrator, as it was brought to the transportation company Director’s attention. After the matter was addressed, the third-party company staff would come inside the facility to pick up the residents. In addition, the facility policy is for all residents are to sign themselves in and out on the facility’s logbook. Based observation and interviews the allegation of facility is allowing resident to leave unassisted is unsubstantiated at this time.

Facility staff not following physician's orders It was reported that R1 had a doctor’s order for wound care and that the ordered ointment was not being placed on the wound. Per the interview with the Administrator Ann Marie Santos. Ms. Santos stated that R1 had a diabetic wound which was not stageable and that have never been without home health. Ms. Santos stated that the diabetic wound has always been overseen by medical provider who provides R1 with a Home Health Nurse, who will come and place the ointment on the wound and are responsible for the care of the wound. Ms. Santos stated that the facility is not qualified to care for the wound due to it being a diabetic ulcer. Ms. Santos is not aware of R1 ever being without Home Health and was not aware that he ever missed the ointment being placed on the wound. In addition, Ms. Santos stated that R1 was sent out to the hospital in March because the wound was not healing even with the ointment being placed on the wound. Further included in the doctor’s order on around 3/25/20, The doctor ordered for R1 to be isolated at facility for a condition that was ***Continued on 9099C