Complaint Investigation Report

As to the allegation, the Administrator (DL) did not allow a healthcare professional to obtain a prescribed urine sample from a client in care, this investigation revealed the following. On 8/22/2022, Client 1 (C1) was visited at Habilitative Homes Residential Care Facility by Healthcare Professional 1 (HP1). During the visit, HP1 noticed C1 was walking funny and although C1 answered most questions correctly during a cognitive test, C1 answered some questions wrong. HP1 believed C1 may be experiencing a Urinary Tract Infection (UTI) and told DL they would be ordering a urine sample to check C1 for a UTI. The order was sent to C1’s home health provider that same evening and the following day (8/23/2022), Healthcare Professional 2 (HP2) went to the facility to collect the urine sample from C1. Interviews revealed that before exiting their vehicle, HP2 was contacted by Staff 2 (S2) who handed HP2 a cellular telephone. HP2 spoke to DL on the phone who told HP2 that they no longer needed to collect a urine sample from C1. HP2 said they were not given the opportunity to check on C1, so they left.

During their interview, on 8/22/2022, DL said C1 was evaluated at the facility by HP1 who did a full assessment and checked C1’s vitals which were normal. DL said HP1 performed a cognitive test on C1 and told DL that C1 was manipulating their answers and purposely answering them wrong. DL said HP1 told them that C1 was in good health. DL said they asked HP1 to collect a urine sample to check for a UTI infection. DL said HP1 told them C1 is fine, and a urine sample was not needed. Allegedly, HP1 told DL they would order the sample since it was requested.

According to DL, on 8/23/2022, at around 9:30 AM, a health care professional arrived at the facility to collect a urine sample from C1. DL told an investigator that they spoke to the health care provider via telephone before they contacted C1. DL told them C1 no longer needed a urinalysis. Investigator asked DL why they changed their mind. DL told the investigator it was because HP1 told DL that C1 was faking their condition.

However, on 8/24/2022, DL called the home health agency several times requesting a nurse to come to the facility and obtain a urine sample from C1. DL told investigators they thought about it throughout the night and decided C1 needed to be checked.

As to the allegation facility staff did not seek and/or arrange medical attention for a client in care, the investigation discovered the following. Interviews revealed that on 8/23/2022, between 7:00 and 8:00 PM, S2 passed C1’s bedroom and observed them lying on the tile floor. S2 assumed that C1 voluntarily laid on the floor because S2 did not hear a fall. S2 did not observe nor was S2 informed by anyone how C1 ended up on the floor. According to S2, C1 refused to get off the floor when asked to get up. S2 said C1 refused staff’s