Complaint Investigation Report

Regarding Allegation #1 : Staff are not following Physicians orders. This complaint alleged that the administrator informed staff not to follow the physicians’ orders of washing the buttocks area with soap and water for R1. On 10/12/2021 LPA Calderon obtained and reviewed the physicians order dated 10/11/2021 for R1. The order states that the back bilateral buttocks and groin will be cleanse with soap and water. The order states the groin will be pat dried gently, and nystatin powder as well as triamcinolone cream 0.1% applied twice a day. The treated area would then be exposed to the open air. LPA Calderon conducted an interview with A1. A1 expressed that all staff follow the physician orders (dated 10/11/2021) for R1. LPA Calderon interviewed S1-S3 and 3 out of 3 staff expressed that they follow the physicians order and were trained to provide R1 with physician ordered care. LPA Calderon obtained and reviewed care plan records (dated 10/19/2021-01/22/2022) and found staff assisted R1 with incontinence services, repositioning, and applying ordered powder as well as medicated creams daily. On 05/12/2022 LPA Calderon reviewed Medication Administration Record for (May 2021) and found nystatin powder and triamcinolone 0.1% cream were administered per the physician’s order. 10/12/2021 LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments. LPA conducted an interview with W1 who visited R1 three times per week and expressed observing R1 being washed with soap and water when visiting. W1 was unable to confirm an absence of care was occurring when W1 was not present.

Regarding Allegation #2 : Staff are not changing R1 diaper timely.

This complaint alleged staff are not changing R1 diaper every 2 hours.

On 10/12/2021 LPA Calderon obtained and reviewed the physicians order dated 10/11/2021 for R1. The order stated that R1 diaper should be changed every 2 hours or when needed. LPA Calderon interviewed A1. A1 state all staff follow the physician orders (dated 10/11/2021) for R1. LPA Calderon interviewed S1-S3 and 3 out of 3 staff expressed that S1-S3 were trained to change R1 diaper every 2 hours or when needed. 3 out of 3 staff expressed that S1-S3 were given incontinent training from A1 (dated 09/13/2021). 3 out of 3 staff expressed that staff keeps incontinent log records on changing resident every 2 hours (dated 10/19/2021 to 01/22/2022). LPA Calderon obtained and reviewed in service training for incontinent care and noted incontinent services provided every 2 hours to R1 (dated 10/19/2021 to 01/22/2022). LPA Calderon conducted an interview with W1 who visited R1 three times per week and states observing R1 incontinent services provided by staff every time W1 visited R1. W1 was unable to confirm an absence of care was occurring when W1 was not present. LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments.