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32 | (Continued from LIC9099 p.1)
Facility staff informed the hospital that it would not be safe to discharge R1 back to the facility due to their self-harming behaviors and persistent attacks toward care providers; staff requested a medication adjustment with observation period. Staff informed that the medication request was granted but not the observation period. R1 was sent back to the facility on 07/30/2026. Staff stated that R1's physical aggression episodes continued immediately upon their return to the facility. Staff maintained that there was not a plan for R1 to move to a different facility and the intention was always for R1 to return after the medication evaluation. Staff informed that after the second attempt for a medication/behavioral evaluation, R1's family was provided with placement resources by an outside entity and the family initiated for R1 to move to a different facility.
During the unannounced facility visit LPA attempted to interview R1. R1 was present at the facility at the beginning of the visit, however they were moved to their new facility during the visit.
LPA spoke with the person responsible for making decisions for R1's care. The responsible person informed that R1 was having behavioral issues and went to the hospital for an assessment, but the hospital did not keep R1 for a full evaluation. The responsible person confirmed that R1 returned to the facility.
LPA reviewed the following relevant records for the investigation: facility care notes, communication between the facility and R1's doctor, shift reports, text messages, and facility census records. The records corroborated staff statements regarding R1's physical/verbal aggression, facility attempts to address R1's change in condition, communication with R1's family, R1's admittance/discharges from two hospitals in an attempt for R1 to receive a behavior evaluation, and R1's return to the facility from both hospital visits.
Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. |