Complaint Investigation Report

ALLEGATION #2: Facility failed to care for resident with restricted health condition.

It is alleged that the facility failed to provide appropriate care for Resident #1 (R1) due to a specific health condition. Reports indicate that (R1) required catheter care, but the staff did not maintain the catheter properly, and the area was not kept clean. As a result, (R1) endured catheter associated urinary tract infections (UTIs) every month. No further details regarding this matter were provided.

On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 through Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to support the claim. (R2-R5) reported that they have no health restrictions classified as a "restricted health condition" and expressed no concerns regarding the care and supervision provided by the staff at this facility.

On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed Staff #1 (S1). During the interview, (S1) admitted that (R1) required catheter care and was under hospice services at the time of admission. Later, (R1) received assistance from home health services for catheter care as well. (S1) claimed that (R1) would also receive catheter maintenance during visits from the primary physician. However, despite (S1)'s assertions that hospice or home health was assisting with catheter care, no documentation was provided as evidence. (S1) acknowledged that this is a restricted health condition but failed to notify Community Care Licensing and did not have a care plan in place to address the restricted health condition.

On April 17, 2025, between 2:30 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) confirmed that (R1) uses a catheter. (R1) stated that the facility staff provided care by transporting (R1) to Veterans Affairs (VA) for a catheter change. However, when asked how often (R1) see the primary physician, (R1) replied, “I never see him.” (R1) also confirmed to have never received any visits from the primary physician while at Harmony Home Care, nor have (R1) been seen by a Hospice Nurse or Home Health Nurse.

The Department reviewed Harbor UCLA Medical Records (dated 03/25/25), (dated 10/03/23), (dated 10/11/23), (dated 11/24/23), and (dated 12/14/24), which revealed that (R1) suffered from repeated urinary tract infections due to the use of an indwelling urinary catheter. A catheter should only be used if ordered by a doctor and included in a care plan that outlines skilled catheter care and proper staff training.