Complaint Investigation Report

The resident was never conserved and (R1) was determined to have “intact cognitive function” following a Neuropsychiatric Assessment on 4/2/2021, until 4/14/22, when a follow up assessment was conducted.

On the Physician’s Report, dated 5/3/21, it is noted (R1) had a diagnosis of Congestive Heart Failure (CHF), Hypertension (HTN) , Coronary Artery Disease (CAD), Gastrointestinal Bleeding (GI bleed) and can bathe, feed and dress/groom herself and care for her own toileting needs. The physician’s report does not indicate that (R1) had a diagnosis of Mild Cognitive Impairment (MCI) or Dementia, and the only allergy noted is for quinolones ( bactericidal antibiotics). (R1’s) care plan completed on 5/27/21 notes (R1) has additional diagnoses of Chronic obstructive pulmonary disease (COPD), walks with her walker most of the time and is able to perform most of her Activities of Daily Living (ADL’s) with some help and gentle reminders from staff.

An updated physician’s report was obtained on 4/12/22 from the same physician. The primary diagnosis is listed as HTN and CHF with secondary diagnoses noted as Hyperlipidemia, Hypothyroidism, Urinary Retention and Atrial fibrillation (Afib). The physician’s report documents (R1) to have MCI, visual impairment, bladder impairment, is able to provide self-care for the same (ADL’s), is able to administer her own medications but is not able to administer her own oxygen. The only allergy noted is for quinolones. ( R1’s) care plan completed on 4/10/22 notes (R1) to have additional diagnoses of Chronic obstructive pulmonary disease (COPD), Chronic UTI’s and a GI bleed and is able to perform some of her ADLs with assistance and gentle reminders from staff. (R1) was determined on 4/14/22, by her primary care physician, to be unable to make her own health care decisions.

The results of the investigation are as follows: