Complaint Investigation Report

According to the administrator/licensee, prior to R1’s hospitalization, R1 already required a higher level of care that the facility can't provide. She stated that R1 was high risk for fall, R1 had many sessions of physical therapy and many doctor’s appointments. She stated that since R1’s hospitalization, she has visited R1 and R1 presented with medical conditions that required a higher level of care such as high risk for fall, difficulty with swallowing, and a foley catheter. In addition, the administrator/ licensee stated she has visited R1 at the skilled nursing facility where she observed R1 of having a one – to – one caregiver and needed a lot more assistance than Sonas Home can provide.

According to R1’s responsible party, initially the administrator/ licensee stated that R1 cannot return to the facility unless R1 had a night sitter because she felt R1 was at risk for fall and R1 needed a higher level of care so the responsible party spoke with Golden Gate Regional Center and a night sitter was granted. Then, administrator/licensee stated that the sitter needed to be trained so they can care for R1. The responsible party stated that the administrator/licensee was making excuses not to take R1 back despite R1 being back to his/her baseline upon discharge from the hospital. In addition, the responsible party stated that R1’s discharge documentation from the doctor indicated that R1 can return to the board and care home with increased caregiver support.

According to the GGRC Representative, GGRC was in support of R1 returning to the facility as it was recommended by R1’s hospital discharge planner and hospital physician. GGRC has arranged for additional staffing support upon R1’s return. In addition. The licensee was informed that they would work with the facility either to provide additional staffing support to care for R1 or assist with discharge planning in a proper process.

According to the hospital discharge planner, R1 required some assistance with Activities of Daily Living (ADLs) but R1 did not get up unattended at night. The discharge planner stated that the discharge plan was for R1 to return to the board and care, but the administrator did not want to take R1 back due to lack of staff at night. Subsequently, additional night staff was provided but the administrator continued not willing to take R1 back. Therefore, R1 was discharged to a skilled nursing facility despite R1 being back to baseline upon discharge.