Complaint Investigation Report

Staff failed to change residents’ diapers in a timely manner.

RSD stated that residents in memory care that are incontinent are checked every 2 -3 hours and changed as needed. This is not documented as it is part of the daily schedule for care givers.

R2 is wheelchair bound and spends most of her day in her wheelchair. When R2 needs to be changed R2 is taken by staff to her bedroom and placed in her bed to be changed. RSD stated there is no record of R2 having any pressure sores.

R2 weighed 134.8 lbs. on 3/3/22 and 127 lbs. on 3/01/23 for a weight loss of 7.8 lbs. which is 5.7 percent. This is with-in the normal range of a person in their late 80’s. R2 also takes Ensure daily to help with weight maintenance.

ADM reported that the memory care elevator was out of service for a period of 6 – 8 weeks while the elevator was getting an upgrade. The elevator was back in service on 4/04/23.

RSD reported that R2 bruises easily due to the medications she takes. R2 is a fall risk but hasn’t had a fall in over 1 year.

This agency has investigated the complaints alleging staff failed to change residents’ diapers in a timely manner, staff not repositioning resident, resident had unexplained weight loss, facility elevator is inoperable, and resident fell resulting in a bruise. We have found that the allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED .

Exit interview conducted, a copy of this report provided.