Complaint Investigation Report

LPA Marrufo was able to interview RP and it was shared that R1 actually had a bad UTI that was missed, so R1 was treated like he/she was totally out of their mind because R1 has mental illness. LPA Maruufo also interviewed three staff members. S1 mentioned that he/she hasn’t noticed anyone with urinary tract infection (UTI). S1 also has observed R1 to be wanting his/her family member (F1) to be with him/her 100% of the time. When F1 leaves, R1 moves his/her arms and legs and wants to smoke, but when her F1 comes, he/she doesn’t move his/her arms or legs. S2 shared that there has not really been anything S2 have seen where a resident has a change of condition. S2 has also observed that R1 acts weird when R1s family is here. When the family is not here, R1 can get out of bed and walk to the bathroom. R1 walks and goes to the toilet by himself/herself. R1 sometimes needs a little bit of help to clean. R1 puts his/her clothes together. S3 added that R1 went into the hospital about a week ago on a Tuesday or Wednesday. R1 went to the hospital for a UTI. Staff didn’t really observe any changes in R1 before that. R1 has always been a little slouched over all the time since R1 got here.

Based on records review, R1 was seen by P1, on 8/1/2023, who came to the facility to check on other residents. P1 is not R1s primary care physician. R1 was sent to the hospital due to P1s observation of R1 not looking right. R1 was sent and came back with a diagnosis of UTI. Last observation recorded in the progress notes was from 7/20/2023.

Regarding the allegation of staff did not ensure record of centrally stored medications was complete, RP stated that a staff (S1) said he/she is giving R1s antibiotic but when RP looked at the medication list last Friday (8/4/2023) the antibiotic was not listed.

LPA Donato reviewed the documents obtained by LPA Marrufo. It was shown in the Centrally Stored Medication and Destruction Records (CSMDR) that the start date of the antibiotic prescribed by the doctor was on 8/3/2023, it was filled by the pharmacy on 8/2/2023.