Complaint Investigation Report

Staff failed to obtain timely medical attention.

On October 28, 2022, it was alleged that Client #1 (C1) sustained a fall on or about August 2021 resulting in a Subarachnoid bleed. Per Mayo Clinic “A subarachnoid hemorrhage is bleeding in the space between the brain and the tissues that cover the brain. The space is known as the subarachnoid space. A subarachnoid hemorrhage is a type of stroke. It is a medical emergency that needs treatment right away”. An interview conducted with a third-party witness revealed that on March 18, 2021, C1 was sent to the hospital by Licensee Manuel Vazquez as C1 was displaying confusion and lack of energy. Per scans conducted revealed C1 to have a small aneurism in front on the left side of their head. A specialist ordered C1 to wear a helmet and discharged C1 back to the facility on March 23, 2021. A review of facility notes revealed that there was no record that indicated that R1 had a fall in August 2021, resulting in a Subarachnoid bleed. There is no record or recollection from any witnesses interviewed to support that C1 had a fall in August 2021 resulting in C1 sustaining a subarachnoid bleed. Based on insufficient evidence to support the allegation, the allegat ion of Staff failed to obtain timely medical attention is unsubstantiated.

Staff failed to follow reporting requirements.

It was alleged that some things would not get reported in a timely manner pertaining to the clients, and there would be no follow up on recommendations for client care. It was alleged that Client #1 (C1) would become constipated, as there were times when they did not have a bowel movement for up to five days. It was recommended to have C1, sent out for further medical evaluation by the facility’s Nurse Consultant. LPA reviewed a Special Incident Report (SIR) dated 07/14/2021 that notes C1 was seen at the emergency room due to constipation, with the after-care visit summary attached. The SIR does not state how many days C1 had been constipated for. Upon further records review of a special incident report (SIR) dated 10/09/2021 revealed C1 had a fall and was sent out for a medical evaluation the same day. This was corroborated by the aftercare visit summary dated 10/19/2021. There was no further documentation to review that would support that the facility did not seek timely medical attention in a timely manner therefore the allegation is unsubstantiated.