Complaint Investigation Report

Allegation #1: Staff did not provide adequate supervision, resulting in a resident slipping in the shower.

Allegation #2: Staff did not meet resident’s hygiene needs.

The details of the complaint alleged due to inadequate supervision resident #1 (R1) slipped in the shower. It is reported that due to ineffective staffing (R1’s) hygiene needs are not met caused by delay and refusal from staff.

On 03/04/24, between 09:46 am – 10:30 am, the Department interviewed staff #1 (S1) who stated these allegations are false. (S1) claimed (R1's) needs have special requirements. (R1) when using the shower water gets everywhere. (R1) requested for a non-slip in the bathroom but wanted the chemical applied to the whole bathroom and the facility complied to (R1’s) request. (R1) felt hygiene needs were not being met and requested for new toilet did not like the toilet that is provided, and it had nothing to do with facility staff not being able to provide basic services timely. (R1) fell in the shower on 01/15/24, with the assistance and supervision of (R1’s) private care provider present. (S1) indicated that (R1) maintains independence and required no assistance with personal grooming and hygiene needs. (R1) requires assistance with set up of showering material assisted by (R1’s) private care provider. (R1) has been evaluated did not require status checks all according to (R1’s) Facility’s Evaluation Report (dated: 01/15/24).

On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (3) out (6) staff #4, #5 and #8 (S4-S5 and S8) were able to confirm of (R1’s) fall and that (R1) received immediate assistance. (S8) indicated that (R1) had the tendency to take showers 3 or 4 times daily and during the fall, (R1’s) private care giver was present when the incident occurred. (S5) reported that (R1) at time refused assistance in the shower twice on 01/15/24 which probably contributed to (R1’s) fall. According to (S4), an incident report was created, and that staff responded to (R1’s) fall right away.

Five (5) out of six (6) staff #5-#9 (S5-S9) were interviewed who stated to have had direct care with (R1) and assisted with (R1’s) hygiene needs. As described by (S6), (R1) is challenging when it comes to hygiene assistance. Nevertheless, when requested by (R1), the proper care will be provided.

On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (4) out (6) residents #3- #6 (R3-R6) affirmed they are independent and did not need staff assistance nor have experienced a fall.