Complaint Investigation Report

Allegation #2: Staff did not meet the residents' incontinence needs.

It is alleged that facility staff did not meet residents’ incontinence needs. It was reported that residents were left soiled during the evening hours and did not get their diapers changed, and developed pressure injuries. No further details have been provided concerning this allegation.

On May 15, 2025, between 10:00 AM and 2:00 PM, the Department interviewed resident members identified as Resident #1 through Resident #5 (R1-R5). Three (3) out of the five (5) could not validate this allegation. (R1, R3, and R4) stated having no concerns or issues with incontinence care. (R4) praised the staff, highlighting their responsiveness and willingness to assist. (R2 and R5) were interviewed, but their health conditions affected their communication ability. They could not carry out full conversations.

On May 15, 2025, between 10:00 AM and 2:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #4 (S1-S4). Four (4) out of the four (4) staff members could not support this allegation. (S1) stated that they had not heard any dissatisfied residents or family members complaining about incontinence care. (S1) explained that diaper care for residents is based on each resident's care plan. (S1-S4) explained that residents requiring incontinence assistance are served four times daily or as needed and that no residents are left in soiled diapers. Staff members (S1-S4) reported that no care residents have ever developed bedsores. (S1) stated that residents in care have static air mattresses that prevent pressure sores due to limited mobility. Residents are repositioned every two hours to prevent pressure injuries, and staff received training from hospice and home health on how to avoid these injuries.

On May 13, 2025, and May 15, 2025, between 10:40 AM and 2:00 PM, the Department interviewed witness members identified as Witness #1 through Witness #3 (W1-W3). Three (3) out of the three (3) witness members could not verify the allegation. (W1) the Program Director at Morningside Adult Day Health, described (R2, R3, and R5) as well groomed, cared for by staff, and has never appeared in soiled clothing or diapers at the day program. (W2 and W3) Home health services representatives verified that (R1) was receiving home health services, the aides staff provided incontinence care, and there were no indications from home health aides that (R1) had incontinence problems.