Complaint Investigation Report

Allegation: Staff leaves residents soiled for an extended period of time.

It is alleged that staff leave residents soiled for extended periods of time. During staff interviews, staff consistently reported that facility policy requires residents requiring incontinent care to be checked, changed, and repositioned every two hours, or more frequently as needed. However, several staff members expressed concerns that this schedule was not consistently followed during the overnight (NOC) shift. Although some staff denied personally observing residents being left soiled, multiple staff members independently reported instances of delayed overnight incontinent care and residents being found soiled at the beginning of the day shift, raising concerns regarding the consistency of overnight care.During resident interviews, all eight residents (R1–R8) reported that staff assist them with their incontinent care needs. While several residents stated there are occasional delays in staff responding because caregivers are busy, they consistently reported that staff ultimately provide the necessary care and did not report being routinely left soiled for extended perio ds.

Allegation: Staff are double diapering residents.

It is alleged that staff are double-diapering residents. During staff interviews, staff consistently reported that facility policy prohibits double-diapering residents and stated residents requiring incontinent care are to be provided with appropriate briefs and timely changes. Several staff members acknowledged that double-diapering had occurred in the past or that residents have requested to wear two briefs. S7 stated some caregivers previously complied with resident requests to wear double briefs but reported nursing staff instructed caregivers that the practice is not permitted. S8 similarly stated double-diapering occurred when they first began working at the facility but reported it no longer occurs. S3 and S6 stated some residents have requested to be double-diapered; however, staff explain the practice is prohibited because it may contribute to skin irritation and skin breakdown. Several staff members also stated the facility conducted an in-service training for all caregivers emphasizing that double-diapering residents is not permitted. Staff reported they signed documentation acknowledging the training and understood that residents should receive timely incontinent care rather than being double-diapered. During the investigation, the facility provided LPA with a copy of the in-service training and staff sign-in sheet documenting that caregivers received training on the prohibition against double-diapering residents. During resident interviews, no residents reported being double-diapered or stated they had observed staff double-diapering other residents. Residents who required incontinent care reported staff provided assistance with toileting and changing as needed.