Complaint Investigation Report

Staff stated that C1 was not on a modified diet and fed a regular diet. Staff also said C1 would only eat pizza on outings, which were not frequent. LIC602 Physician’s Report, signed June 16, 2021, also indicated that C1 was not prescribed to a special diet. Facility records indicated that C1 was not conserved and had the access and choice to eat food not provided by the facility. C1 moved to a different licensed board and care around May 2022. At the new facility, Administrator stated that C1 was on a low carb diet. Administrator also stated C1 ate items that were not in their physician recommended diet when they went out and visited with family, which was frequently. The allegation that staff did not provided a modified diet as prescribed by their physician is found to UNSUBSTANTIATED.

Medical records also indicated that C1 was considered obese with Type 2 diabetes on February 6, 2022. At the time of their hospitalization, C1 was reported to have had a BMI of 30. Facility records indicated that in February 2022, C1 was 4’7” and 137lbs. The Department’s Clinical Consultant reviewed C1’s medical record from their hospitalization on February 5, 2022 and they did not indicate that client was deficient in nutrients. Therefore, the allegation that the food quality at the facility did not meet client’s nutritional needs is found to UNSUBSTANTIATED.

On January 11, 2022, the facility self-reported an incident regarding C1 having a seizure. Facility documents indicated that as a result of the seizure, C1 was prescribed a new medication on January 14, 2022. The facility self-reported to the Department that C1 was sent to the hospital on February 5, 2022 due to C1 having difficulty standing up. Medical records indicated that the medication prescribed had caused C1 to have had increased difficulty ambulating which was the primary reason for the hospitalization. The Department’s Clinical Consultant reviewed the medical records and determined that they not indicate that C1 was dehydrated. Staff also confirmed that C1 drank at least a 16oz bottle water at every meal. Administrator of C1’s current home indicated that C1 enjoys drinking water and does so consistently on their own. The allegation that staff did not ensure sufficient fluid intake is found to be UNSUBSTANTIATED.

Based on the evidence obtained during the complaint investigation, the allegations that staff did not provide a modified diet prescribed by physician, that food quality did not meet client's nutritional needs, and that staff did not ensure adequate fluid intake for client is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with caregiver; a copy of this report and Licensee's Rights (LIC9058) were provided.