Complaint Investigation Report

Allegation: Staff do not ensure resident’s incontinence needs are met.

The allegation alleges that during the night the caregivers do not check on them or change their diapers.

During the facility inspection, LPA observed staff asking residents if they need to go to the restroom or if they need changed.

During record review, LPA received and reviewed Resident R1’s Service Plan (dated 07/29/2025) that indicates R1 requires assistance with PM and nighttime incontinent care. LPA observed safety checks are to be done four (4) times per shift is listed as a Special Care Need. LPA received and reviewed Resident R1’s Physician Report (dated 09/30/2024) that comments patient requires assistance with toileting. Additionally, LPA received and reviewed Staff S2-S10 training records that indicate staff have received the following training on Relias within the last year, Restorative Nursing: Bowel and Bladder for the CNA, Managing Urinary Incontinent, and Care of the Bedridden Individual. LPA received and reviewed In-Service logs regarding Handling Residents with Care while Providing Incontinent Care, Peri Care, Toileting Log, and Incontinent Supplies.

During interviews with Staff S1-S10, were asked how often residents are checked/assisted with changing briefs/diapers, ten (10) out of ten (10) stated they are checked/assisted every 30 minutes to two (2) hours depending on the residents. Additionally, Staff S1-S10 were asked if there was a time when they came into work and observed a resident in soiled diapers, seven (7) out of ten (10) stated no, they have not come into work and found a resident in soiled briefs/diapers. Three (3) out of ten (10) stated there was a time when they have come in and a resident was soiled, and they were informed during crossover, the resident at the time was refusing assistance with being changed.

During interviews with Residents R1-R7, they were asked if there has been a time they were left in soiled diapers for an extended period of time, three (3) out of seven (7) stated no they have not been left in soiled diapers or briefs for an extended period of time. Two (2) out of seven (7) stated they had been left in soiled diapers for 5 to 15 minutes due to staff assisting other residents. Two (2) out of seven (7) stated they do not require assistance changing their briefs. Additionally, during interviews Residents R1-R7, were asked if staff check on them during the night to see if they need changed, five (5) out of seven (7) stated yes, staff come and check on them at night to see if their diaper or briefs need changed. Two (2) out of seven (7) stated they are not sure if staff check to see if they need changed at night.