Complaint Investigation Report

Allegation: Staff did not assist client with incontinence needs in a timely manner. The complaint alleges that for 5 days in a row [dates unknown] staff may have only changed client (C1) once between the hours of 8:30 AM - 1:30 PM. The client was always sent with 5 diapers and 5 chucks, but during that week the client returned home with 3-4 diapers. According to information obtained, C1 typically urinated at least 4 times within a 5 hour period, which would have required the use of all 5 diapers sent to the day program. A total of 4 clients were interviewed. They all stated they observe staff providing incontinence assistance. Client (C1) is non-verbal and was not interviewed. Based on interviews and record review, the investigation revealed that lead Life Skills Coach (S1) and relief staff (S2) were initially checking C1 every 15 minutes, then proceeded to check the participant every hour, but during incontinence assistance staff observed that C1 was soiling through. Therefore, both staff started checking C1 every 30 minutes. All staff denied any negligence with incontinence assistance. Staff stated that clients are provided incontinence assistance, and client (C1) was typically changed three times during programming. However, based on record review of T-Log, 5 Refresh Check-Off Lists, and C1's Daily Log staff did not consistently document that checks and assistance was being provided to C1 and other clients. The facility uses Therap Services software, in which only 2 entries pertaining to C1's incontinence care was referenced. LPA requested plan of operation and continence care manage plan, but a year 2000 Program Narrative was provided that did not include a continence plan.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED .

An exit interview was conducted with Program Director Erick Vasquez . A copy of the report and appeal rights were issued.