Complaint Investigation Report

OS1 stated they also contacted Hospice, who responded to the facility, assessed R1, and determined R1’s vital signs were stable with minor wound drainage. Hospice informed OS1 that an evaluation at a hospital would be reasonable. Based on this, OS1 requested non-emergency medical transport rather than 911 transport, and Hospice agreed. OS1 also requested that R1 be transported to a specific hospital where R1’s established specialists were located, which Hospice also confirmed was appropriate. It was also revealed that the Emergency transport (OSA1) from the original 911 call had arrived and provided OS1 that R1’s vital signs were normal, and the wound showed no active bleeding. OS1 also stated contacting the COO with this information and requested non-emergency transport. According to OS1, the COO agreed. It was revealed that then the Emergency transport (from the original call) discharged R1 while they were still at the facility. However, OS1 stated the facility contacted 911 again and R1 was transferred to an Emergency Room (ER).

OS1 stated the COO later contacted them and informed them they did not have the authority to make requests for staff. The COO further stated that if OS1 continued calling, R1 would not be allowed to return to the facility, and they would be contacting the police. The COO then text messaged OS1 they were calling 911 and ended the call. OS1 reported sending text messages attempting to determine R1’s location after transport. The COO responded, “you are being told not to interfere.” Around 11:00 PM, a staff member texted OS1 and reported that the COO instructed staff not to allow R1 back into the facility unless staff contacted the COO first. OS1 attempted to reach the COO multiple times but did not receive a response. With no information provided by the facility, OS1 visited multiple emergency rooms that were able to provide OS1 R1’s location. OS1 found R1 in the ER, accompanied by the emergency transport, who also reported R1 was stable.