Complaint Investigation Report

The investigation consisted of the following: LPA Calderon interviewed Staff (S1-S3), client (C1-C2) and witness (W1-W2). These interviews were conducted on 02/20/2024 and 02/22/2024. LPA Calderon obtain and reviewed the following: Physician’s report (dated 02/01/2024 to 02/29/2024) Needs and Service Plan (date 02/26/2020), Incident report (dated 01/08/2024), Gastro-Jejunostomy (G-Tube) training logs (date 06/29/2023), Harbor Regional Center incident reports (date 01/08/2024, 02/14/2024), daily body checks log notes (date 02/01/2024 to 02/21/2024), urine output log notes (date 02/01/2024 to 02/21/2024) for C1.

Regarding Allegation #1 : Staff did not meet a resident’s care needs.

This complaint alleged lack of care as staff did not change C1 diaper prior to leaving facility. LPA Calderon interviewed with S1. S1 stated that S1 arrived at the facility around 8 am and was advised by W1 that S3 had not changed C1 diaper prior to leaving for Webster House. S1 states that W1 had cleaned C1 G-Tube area and had changed C1 diaper. LPA Calderon interviewed W1 who states that W1 arrived at the facility around 8 am and S3 had just left for Webster House. W1 states that W1 checked on C1 and noticed that C1 diaper was wet with urine and S3 had not changed C1 diaper prior to leaving. W1 reported the lack of care to S1. LPA Calderon interviewed staff (S2-S3). S2 states that S2 was not working on 02/14/2024 and did not witness the situation with C1. S2 states that S2 works with C1, and staff are to check C1 diaper every two hours and change resident diaper daily or when needed. S3 states that S3 arrived at the facility at 6:40 am and checked on C1 around 6:45am. S3 states that C1 was dry and C1 diaper did not need changing. S3 states that S3 was told by S1 to move to Webster House for work. S3 states that S3 waited for W1 to arrive prior to leaving. S3 states S3 should have checked on C1 prior to leaving for Webster House. S3 states S3 did not know what to do and S3 should have changed C1 diaper prior to leaving the facility. S3 states that not changing C1 diaper was a mistake and not a lack of care. LPA Calderon conducted an interview with W2. W2 states that W2 arrived at the facility around 8:15 am and S3 had left for Webster House. W2 did not witness if S3 had checked C1 diaper prior to leaving the facility. W2 states that W2 does not believe that S3 did not care for C1 needs as W2 states that W2 has checked clients in the past and the client’s diaper was dry and seconds later was wet with urine. W2 states that what happened to S3 could happen to any staff member. LPA Calderon attempted to interview C1 who was non-verbal and could not answer any questions. LPA Calderon interviewed C2 who states that staff takes care of C2 medical needs. C2 states that C2 does not wear a diaper and cares for C1 needs except meals and medications.