Complaint Investigation Report

The administrator stated there are no other staff or residents currently. Due to the lack of records and eyewitnesses during this investigation, LPA Reed referenced pertinent interviews and record review of R1’s records from investigation of complaint # 31-AS-20240730093716 on 08/06/24.

Regarding the allegations "Staff did not ensure catheter care was being provided to resident" and “Resident’s incontinence care was neglected in the facility”, it was alleged that facility staff did not provide catheter care for R1 which led to their hospitalization on 08/07/24 for a urinary tract infection (UTI) with a foul odor. Interview with the former administrator at 9:35 a.m. on 08/06/24 revealed R1 was hospitalized on 07/26/24 for ‘excessive eating and drinking’. R1 returned with a catheter and home health services to assist with catheter care. The facility refused R1’s home health agency from entering the facility and instead used their own home health agency and in-house nurse. Follow up interview with the former administrator around 10:30 a.m. on 02/28/25 revealed the in-house nurse visited R1 once and said that the catheter only needed to be changed once per month. Therefore, no catheter care was provided. The former administrator also noted that the facility did not obtain refills of R1’s medications and did not assist with R1’s medications at the request of R1’s friend. Interview with S1 at 10:10 a.m. confirmed that the facility did not assist with R1’s medications for at least one month at the request of R1’s friend. Interview with R1’s friend at 11:00 a.m. on 08/06/24 revealed that they were not R1’s responsible party and were not on any of R1’s admission documents. R1’s friend noted that they told the former administrator to wait for all physician’s orders to arrive before assisting with medications and incontinence care. Interview with R1 at approximately 12:00 p.m. on 02/28/25 revealed they were never visited by a nurse or provided care for their catheter. When LPA visited the facility on 08/06/24, LPA observed R1 walking with their catheter bag in a dirty 5-gallon bucket. Record review of R1’s records on 08/06/24 at 10:30 a.m. revealed R1 had a history of UTI. No staff trainings were available regarding catheter care. No physician's orders for R1's catheter were present. Interview with the licensee at approximately 10:00 a.m. on 02/28/25 revealed they did not know where records were or if staff had any trainings. Six (06) out of six (06) residents interviewed on 02/28/25 had no pertinent information about R1. Based on observations, interviews, and record review, staff did not provide catheter care or incontinence care to R1 and had no training in catheter care. Home health also did not assist with R1's catheter care. Therefore, the allegations are deemed SUBSTANTIATED at this time. A deficiency is cited on the corresponding LIC 9099-D page.

Exit interview conducted. Appeal rights discussed. Copy of report provided.