Complaint Investigation Report

According to R1’s Admissions Agreement contract, Face Sheet, and other administrative records, R1 moved into Mesaview Senior Assisted Living (“Mesaview”) in late October 2021 as their own responsible party. R1 was concurrently a patient of a third-party managed health group (HG), where R1’s primary physician (P1) worked. Per R1’s LIC624 Physician’s Report, their end-stage renal disease primary diagnosis required them to attend offsite hemodialysis on “Tuesdays, Thursdays, and Saturdays.” P1 wrote R1 was “non-ambulatory,” used a wheelchair, and required assistance with mobility, toileting, and other personal care due to their right foot being partially amputated. R1 also had anemia, diabetes, a pacemaker, cataracts, mild hearing loss, and was alert and oriented but sometimes confused. R1’s LIC603 Pre-Placement Appraisal showed they were “non-ambulatory,” “feeble/slow,” used a wheelchair, and needed help with mobility, transferring, and toileting. Licensee’s Care Plans and Reappraisals on R1 echoed the above points and described R1 as “mildly confused,” “slightly forgetful,” and “can stand [and bear weight,] but not for long.” R1’s facility medication list, corroborated by HG and hospital records, showed R1 was taking two blood-thinner medications during timeframe of the alleged incident.

CCLD reviewed two pertinent LIC624 Incident Reports which licensee submitted before the current complaint was received. According to licensee’s first LIC624: on 11-26-2021 around 3:00 PM, Mesaview direct-care Staff #1 (S1) received a phone call from R1’s offsite dialysis center (DC); DC staff reported R1 was found on the floor of the center’s restroom. (This LIC624 did not indicate if R1 had injuries but said Mesaview staff contacted R1’s HG physician). According to licensee’s second LIC624: on 11-29-2021 around 4:00 AM, Mesaview direct-care Staff #2 (S2) called 911 because they observed R1 “having difficulty communicating and drooling.”

According to the dialysis center’s date and timestamped electronic notes, R1’s underwent a hemodialysis session on Saturday 11-27-2021 (and not Friday 11-26-2021, as was stated in licensee’s LIC624s and LIC624A). Per the center’s 11-27-2021 notes: a DC registered nurse (P2) wrote that R1 “was seen on the bathroom floor [with] the wheelchair on [their] back.” P2 and coworkers helped R1 get back into their wheelchair to finish using the restroom. R1 complained of “pain in both knees,” for which a “PRN [as-needed medication] for pain [was] given.” R1 had “no swelling or bruises noted.” [CONTINUED ON LIC 9099-C, 2 of 4]