Complaint Investigation Report

On June 16, 2024, LPA David Marrufo interviewed ADM. ADM stated R1 had changes in his/her conditions on May 20, 2023. ADM stated on May 21, R1 started to refuse food and at lunch time R1 didn’t want to eat anymore. ADM stated R1 went to the emergency room. ADM noted R1 was not complaining about any abdominal pain. ADM stated he/she notified R1’s physician and R1’s Power of Attorney (POA). ADM stated after two days the facility was informed R1 had a UTI and was transferred to a rehab center.

On October 30, 2024, LPA Monter interview staff S1 and S2. Both staff interviewed stated if they see any change to a resident’s condition or baseline, they will inform the ADM about said changes. Both staff interviewed stated they have been working at the facility for 7 months and did not work with R1.

LPA interviewed ADM. ADM stated she works at the facility 5 days a week, 8 hours a day. ADM stated she was the one who noticed the change in condition regarding R1. ADM stated she informed R1’s doctor and R1’s POA. ADM stated she called for an ambulance for R1 to be checked. ADM also stated her staff inform her of any changes in the residents’ conditions.

Based on a review of R1’s progress notes (PN), on May 14, 2023, R1 has not had a bowel movement. PN stated Medications and prune juice given to manage, but ineffective. Resident R1’s physician was notified and R1’s family members. On May 15, 2023, R1 still has not had a bowel movement & R1’s physician and family members were notified. Facility received a call from clinic stating physician assistant would arrive and administer suppository. R1 had a bowl movement later that evening.

Based on a review of R1’s PN, On May 21, 2023, R1 refused to drink liquids at 7:30am. At 11:30am, R1 refused to eat and drink liquids. R1’s doctor and POA was notified. A facetime call done with nurse who assessed R1. The Nurse recommended to take R1 to urgent care/ ER for evaluation. R1’s POA notified and agreed to send R1 to ER. The facility received a call and was informed about R1’s Urinary tract infection. On May 22, 2023, the facility received a call from the hospital and was informed that R1 had been treated for sepsis (bladder infection) and was not ready to come back to the facility.