Complaint Investigation Report

Allegation: Staff do not ensure client is accorded safe, healthful, and comfortable accommodations. It is alleged client (C1) in room 8 was defecating and urinating in it's room, bathroom, and on the walls. The other client living in the room had to frequently leave so that staff could assist C1 with cleaning. As a result, C1 was moved to room 7 and isolated to protect other clients. The psychosocial rehabilitation treatment program is designed to stabilize and/or increase independent living skills. C lients are expected to maintain their hygiene, cleanliness of their room, wash their own linens/clothing, perform their own ADLs, shower daily, and keep room free of odors. Clients have assigned chores; of which C1 was not performing. Staff provided C1 clorox wipes, Febreze, and prompted the resident to clean room, wash bedding linens, and maintain hygiene. LPA conducted a physical plant inspection of C1's room (7) and room 8 no unhealthful or uncomfortable accommodations were observed. Client (C1) stated it is provided safe and healthful accommodations, and that staff conduct frequent checks, assist with bedding sheet changes, ensure the room does not smell, and have sprayed deodorizer in the rooms. One (1) out of five (5) clients interviewed reported issues with accommodations related to C1's incontinence issues, but stated staff were trying their best to encourage C1 to use the bathroom and maintain hygiene. All staff stated clients are expected to do their own chores, clean their room, do own laundry, and take out the trash. Staff were assisting C1 in order to maintain comfortable accommodations for C1 and other clients living in the room .

Allegation: Staff are not ensuring incontinent client is kept clean. Based on record review and interviews conducted the findings indicate that the facility is a psychosocial rehabilitation treatment program designed to stabilize and/or increase independent living skills of clients in care. Staff do not provide incontinence care. They prompt clients to use the bathroom and maintain proper hygiene. It is alleged that C1 was defecating on self. Staff interviewed stated C1 was prompted every 30 minutes to go to the bathroom and clean self. The facility purchased sheets, clothing, and a new mattress. C1 refused to shower after bowel movements and would lay in bed soiled. Per Physician Report (1/28/222), C1 had the capacity for self care, and did not require toileting assistance. The facility completed an Appraisal on 3/2/2022, and noted decompensating of as evidenced by self-neglect and refusing to use bathroom for toileting needs. Facility staff contacted DMH, PET teams due to C1's self-neglect behavioral issues. However, C1 did not meet psychiatric hold criteria. Staff continued to prompt C1 with incontinence care, but the client refused. Multiple incident reports were addressed with Mental Health agencies and CCL regarding this issue. All clients interviewed stated staff provided assistance and prompting to C1, despite the facility not normally offering incontinence service care for independent clients in care. Staff do not provide bathing assistance.