Complaint Investigation Report

Regarding allegation: 1.) Resident was hospitalized due to a urinary tract infection resulting from staff neglect. It was alleged that Resident #1 (R1) had three (3) urinary tract infections (UTIs) while residing at the facility, one of which resulted in a hospital stay in November 2023. Medical records from Los Robles Regional Medical Center were obtained for R1 and the following was noted: R1 was first observed at the hospital on 10/25/2023. R1 was admitted to the hospital on 10/26/2023 and was discharged back to the facility on 11/02/2023. R1’s condition throughout the hospitalization were listed in various medical documents as coffee ground emesis, shortness of breath, abdominal pain, chest pain and vomiting. During R1’s hospitalizations, R1 had an upper GI endoscopy procedure done. A physical and multiple tests were performed prior to the procedure, and no immediate complications were listed on the Endoscopy Report. Additionally, R1’s discharge records did not list UTI as a diagnosis. In R1’s home health visit notes dated 03/04/2024, a urinalysis was sent out for a possible, continued UTI. However, a UTI was not listed as a diagnosis. R1 was again hospitalized at Los Robles Regional Medical Center on 03/30/2024 for acute GIB, Sepsis, Asp PNA and Complicated UTI. R1 was discharged on 04/11/2024; however, R1 was already moved out of the facility and moved into another facility. R1 moved out of the facility on 03/24/2024. The information obtained during the investigation did not include evidence sufficient to corroborate the above allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding allegation: 2.) Facility staff did not meet resident’s incontinence care needs. It was alleged R1 was found on multiple occasions sitting in feces and with feces around R1’s scrotum. Per record review, R1 was admitted to the facility on 08/22/2023. Per R1’s physician report dated 05/31/2023, R1 was not able to care for own toileting needs. LPA Peraldi reviewed R1’s home health visit report notes from 07/10/2023 through 03/25/2024 and the following was noted: there was no mention of R1 being found with soiled diapers or sitting in feces. Interview with the Administrator stated that since R1 was in a wheelchair, staff would check on R1 at least every 2 hours or as needed. The information obtained during the investigation did not include evidence sufficient to corroborate the above allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding allegation: 3.) Facility staff handled resident in a rough manner. It was alleged that facility staff handled R1 in a rough manner resulting in bruising. The complainant did not state where bruises were on