Complaint Investigation Report

Staff did not provide emergency personnel with resident's proper documentation.

On the allegation that staff did not provide emergency personnel with resident’s proper documentation, it is the concern of the reporting party (RP) that the staff at the facility had no information regarding the resident (R1) when EMT personnel arrived to provide care for the resident and were unable to get any information regarding the resident’ medical history or contact information for R1. On 07/26/2023 LPA Campos interviewed the administrator, and the administrator stated that when EMT arrived to provide care to R1 and asked for R1’s personal information, the administrator gave the EMT personnel a copy of the Physician’s Report. Furthermore, the Administrator stated that on a previous EMT visit, the Administrator gave by mistake the original R1’s personal information, so the administrator did not have a copy. The Administrator stated that they gave the EMT, R1’s Conservator’ card and telephone number. On 10/11/2024, LPA Urena interviewed the Administrator, and the administrator stated that they did not recall why R1 was taken to the hospital, and that the protocol when EMT’s arrive to provide care, staff are to give them the residents’ personal contact information (LIC 601), the resident’s physician’s report, and centrally stored medication list, however these documents were not provided to the EMT personnel on 07/16/2023. The physician’s report obtained by LPA Urena was incomplete as it stated to see ‘attachment’ for the diagnosis, however, the attachment was not included/attached to the physician’s report. Staff interviewed stated that they could not exactly remember if the requested documents were available at the time R1 was taken to the hospital. LPA Urena was unable to interview the reporting party, and R1’s Conservator.

Based on the information obtained through interviews, the staff did not provide the EMT personnel with the R1’s medical history, and medication information. Therefore, the allegation that staff did not provide emergency personnel with resident’s medical and history documentation, is deemed Substantiated at this time.