Complaint Investigation Report

On 06/25/2023, R1 was sent out to an acute hospital by staff under the incorrect name. It was advised that R1’s family spent hours trying to locate R1 and was finally assisted by an emergency services operator. R1’s responsible party met with the Executive Director who confirmed that Staff 2 (S2) provided the paramedics with the wrong name. An interview with S2 indicated that S2 mistakenly verified another resident’s name and that the Med Tech confirmed it. S2 gathered the wrong paperwork while waiting for the ambulance. After the family contacted the facility to say they could not locate R1, the facility reviewed the records and realized the mistake. Responsible party was notified and able to locate R1.

Regarding the allegation that staff did not provide records to the resident's authorized person, it was alleged that the facility did not provide Serious Incident Reports (SIRs) to R1’s responsible party. Information obtained from interview with additional witness stated on 03/18/2024 they requested copies of all SIRs, but only received a few. It was also reported that there was an incident in which R1 was choked by another resident and the responsible party was denied a copy of the report. Administrator stated that the Serious Incident Reports were provided to R1’s responsible party on the date of 03/18/2024.

Regarding the allegation that staff did not provide language services for the resident as agreed, it was alleged that the facility did not provide German-speaking services to R1. It was advised that facility administration agreed to provide language cards in order to communicate with Resident, but they were never provided or used. Interviews with the Executive Director revealed that staff used language cards and an app on their phones to translate. Staff interviews indicated that the cards were rarely used. It was also reported that the app began to be used on 06/10/2024. Resident was placed at the facility on 02/28/2023.