Complaint Investigation Report

It was alleged that the facility staff pureed resident (R1)’s food without authorization from R1’s responsible party. On 07/21/2023, 2 staff members were interviewed. Based on staff interview, S2 states that when R1 returned from his/her doctor’s appointment, R1’s responsible party provided the paper that states there was a change in diet to puree from R1’s doctor visit sometime in April 2023. S2 states that R1’s responsible party knew there was a change in diet because R1’s responsible party provided the facility with the diet order. S2 states R1’s hospice team was also informed of the diet change. Based on record review, R1’s physician signed a “diet order and dietary communication” form on 04/21/2023 for a puree diet.

It was alleged that the facility staff are not accommodating to R1’s diet needs by not providing R1 with a nutritional beverage.

The review of records show that R1’s physician’s report dated in March 2023 states a special diet for a nutritional beverage. On 07/21/2023, 2 staff members were interviewed. Based on staff interview, S2 states that they did not follow-up with R1’s physician in March to obtain the physician’s order for the nutritional beverage. S2 states despite the physician’s report in March 2023 stating R1 has a special diet for a nutritional beverage, the facility still requires an actual order from the physician. S2 states that since they did not have an actual physician’s order for the nutritional beverage, they were unable to provide the beverage to R1. S2 states they received an order in June 2023.

The Department has investigated the above allegations. Based on interview and record review the above allegations are unsubstantiated. An unsubstantiated finding indicated that although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. However, a case management visit was conducted on 10/07/2024 due to a violation observed during the investigation. See LIC809 on 10/07/2024.

This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided.