Complaint Investigation Report

During the investigation, it was reported that the resident (R1) is not conserved, and was independent in her transportation, as she took TRAX (bus service), ambulance transportation, hospital services transportation, facility transportation and at times an UBER (vehicle service). The resident was very high functioning, and it was not uncommon for the resident to get herself to her various weekly medical appointments, hospital appointments and outings.

An incident report was submitted to the licensing agency and stated that shortly after midnight, on 03/12/24 the resident contacted Emergency Services (911) to go to the hospital due to pain. The hospital staff advised the resident to come to the hospital if she was in need. It was reported that the hospital had the resident wait in the waiting room for an open bed. Once the resident was seen, she was given pain medication and discharged after 4:00 a.m.

The administrator stated that because the resident is highly functioning and independent and not conserved, the resident knows to contact the facility when she has a need or needs a ride. The facility staff stated that they were not notified to come and pick the resident up from the hospital. The regional center staff reported that the facility staff have been very responsible in trying to work with the resident.

Staff spoke inappropriately to a resident .

During the interview process, the administrator, two staff persons, the nurse, and two regional center staff persons were interviewed. The resident (Resident 1) was not interviewed as she has since moved. Several documents were obtained to include the resident’s Individual Program Plan (IPP), Physician’s Report, Admission Agreement, Client Roster, Medication Administrative Record (MARs), staff names and telephone numbers.

During the investigation, it was reported that the resident has numerous behavioral issues and was seeking to be independent in her living situation. Staff reported that they assist the resident; however, also try to encourage her to be self-reliant as much as possible. It was stated that the resident becomes impatient with the staff when they are not immediately available to assist her.

Although the above allegations mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and all of the above findings are Unsubstantiated .