Complaint Investigation Report

Additionally, C1’s Individual Program Plan dated April 27 th , 2022, states C1 is a non-conserved adult, is to received annual dental checkups and receive medical care by primary care physician and nurse consultant. According to allegations received facility is not providing C1 with medical and dental care or transportation to such appointments resulting in C1 having a dental infection and a respiratory infection but no specific date of incident was provided. Based on C1’s records collected, C1 is non-verbal and unable to communicate needs. Interview with administrator revealed C1 attended dental appointments on the following dates, 8/4/2022, 8/5/2022 and 8/19/2022. Interview with administrator also revealed that C1 was routinely examined by a Registered Nurse. Records collected corroborated that C1 was examined by nurse on 9/21/2022, 10/7/2022, 10/25/2022 and on 11/24/2022 the nurse was contacted to provide an urgent consultation. Based on nurse’s assessment on 11/24/2022, emergency personnel were contacted and C1 was admitted to the hospital for Pneumonia. Facility records revealed C1 was diagnosed with Acute Pneumonia on this occasion. Records also showed that C1 was seen at the emergency room on 12/17/2022 for shortness of breathe, then by mobile physician on 1/5/2023 and had a virtual appointment with primary care provider on 2/7/2023. According to interview with outside source, administrator purchased a vehicle specially for the use of transporting C1 to medical appointments. Interview with administrator corroborated that this vehicle is used to take C1 to all their out-of-home appointments, including their dental appointments on 8/4/2022, 8/5/2022 and 8/9/2022.

It was also alleged that C1 was not being taken out of bed or being provided speech services as stated on C1’s care plan. According to records collected, C1 does not have any specified speech services for communication therapy. Records also revealed that mobility training is not appropriate for C1. Records collected indicate that C1 is to be repositioned frequently to prevent skin deterioration and is to be moved from bed to wheelchair on average of two hours per day for socialization purposes. Interview with staff revealed that C1 received specialized medical equipment to facilitate C1’s movement from bed to wheelchair. Interviews with staff revealed that C1 is taken out of bed daily and provided with a change in scenery. Records collected corroborated that C1 is moved out of bed daily for a minimum of two hours. Interview with outside source revealed no prior issues with facility not following Individual Program Plan’s for C1 or any other clients in care.