Complaint Investigation Report

The facility does not employ skilled medical professionals and requires all residents who need these services to receive it from home health providers or their physician. Home Health records were obtained and documented that a visit was conducted on 08/02/2022 and stated residents’ catheter was draining adequate amounts of clear yellow urine without sediment or odor and vitals were normal. On 08/06/2022, an additional visit was made to change the catheter. Vitals were normal during this period. The Registered Nurse who conducted the visit on 08/06/2022 was interviewed and stated the catheter was placed correctly, as evidenced by resident having clear urine return, but stated the catheter could have been inadvertently dislodged afterwards.

There was not enough evidence obtained to substantiate that facility staff inserted resident’s catheter incorrectly or at all. Therefore, the allegation of questionable death due to non-medical staff misplacement of catheter resulting in R1's sepsis is unsubstantiated.