Complaint Investigation Report

The LPA interviewed staff and reviewed all available records. It is unclear whether the missing urinalysis records the complainant referenced were expected to have been generated while the client was in the facility or prior to admission. The LPA located the “New Admit” urine toxicology log with result in the file. Correspondence with the client also referenced records being faxed from the hospital, and the hospital discharge paperwork confirms that a urine toxicology screen was completed prior to admission.

A review of charting notes shows on 7/22/25, a note documented “…requesting… LABs if available – received/uploaded on SmartCare.” Staff reviewed the electronic file and located the uploaded documents. The LPA is unable to determine which documents were originally provided to the client; therefore, both copies found during the visit will be sent to the client. The second document, while available, is stored in the county system and is a record that could also have been obtained directly from the medical agency that created it.

Based on the record review and staff interviews, the preponderance of evidence has not been met. Therefore, the allegation that staff failed to safeguard residents’ records is unsubstantiated.