Complaint Investigation Report

Allegation: Resident requires a higher level of care.

The complainant alleges resident #1 (R1) required a higher level of care. The complainant did not provide additional details on this allegation. Records indicate that there was no lack of care or supervision with (R1’s) care. Progress notes indicate that (R1) was reassessed each time she was returned from a hospital stay and interventions included repositing and changing every 2 hours. (R1) was readmitted to the hospital on 12/11/20. and was discharged 01/16/21. Medical records indicated during (R1’s) discharge that she would require a higher level of care and that the hospital will be responsible for an appropriate placement for (R1’s) care who eventually was placed on hospice care. Interviews conducted with residents #2-#11 all revealed that have no signs of any residents that require higher-level care. According to staff #1-#8 (S1-S8) there are no residents that are being retained at this facility that require a higher level of care that would violate Title 22 Regulations 87615 Prohibited Health Conditions. The facility continues to implement employee training programs that address the nature of these issues. Based on the information gathered, there is no evidence to support the allegation mentioned above.

Allegation: Resident left in a soaked diaper and urine saturated dressing.

It is alleged resident #1 (R1) was left in a soaked diaper saturated with urine. The complainant did not provide additional information on this allegation. The administrator (S1) stated caregiver’s responsibility is to assist the residents with activities of daily living (ADL). Caregivers could be responsible for up to 10 residents at one time. When a caregiver is notified of a diaper or bedding change, the caregiver will address the matter immediately. Moreover, caregivers are trained to use aided equipment to help maneuver residents who are heavy to clean them. (S1) claims in the situation with (R1) when admitted in 2015 was medically evaluated as independent health condition declined each time she was in and out of the hospital. (S1-S2) claims that (R1) was being assisted by caregivers (R1) was being assisted with diaper changes every two (2) hours and repositioned. (S2-S8) all verified residents are monitored at least three times during each shift within the eight hours. (S2) further asserted, it would be improbable to have (R1) in soiled diapers for more than (2) two hours as she was changed every two (2) hours. Interviews with residents #2-#11 (R2-R11) all claimed they had no problems with the staff and found them to be attentive and responsive to their care and needs.

Evaluation Report continues on LIC 9099-C