Complaint Investigation Report

Regarding the allegation “Staff did not meet a resident's showering needs while in care” it was alleged R1 had not showered in twelve (12) days due to lack of assistance. Interview with R1 at 12:45 p.m. on 12/13/2023 revealed they had only showered six (06) times in two (02) months. R1 knew they had missed their scheduled shower time but liked to sleep until noon. Interview with the previous ED at 11:00 a.m. on 12/13/2023 revealed staff follow the facility’s shower schedule to coordinate shower times. The facility offers alternate times to residents if they miss their scheduled time. Although R1 originally chose 10 AM as their preferred shower time, R1 refused a shower on 12/12/2023 due to it being too early. LPA observed Staff #1 (S1) exiting R1’s room around 9:20 a.m. on 12/13/2023. Interview with S1 at 9:30 a.m. on 12/13/2023 confirmed R1 had refused their shower on 12/12/2023, so S1 offered to shower R1 on 12/13/2023. R1 refused the shower the again. S1 further stated other residents also refuse showers occasionally. Record review of the facility shower schedule confirmed R1 was scheduled for showers 10:00 a.m. on Tuesdays and Fridays. Review of shift notes from 12/15/2023 revealed R1 refused their shower. Based on interviews and record review, the facility offered shower services to R1 which were occasionally refused. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff allow a resident to be soiled for an extended period of time” it was alleged R1 remained in soiled diapers throughout the night when staff did not check on them. Interview with R1 revealed they had experienced consecutive days in which they were changed at 10:00 p.m. then changed again at 9:30 a.m. the following day. R1 stated S6 was the only staff to change them more than once during the night. Interview with S6 confirmed they changed R1 throughout the night at 1:00 a.m. and 5:00 a.m., and R1 “kissed their hand”. Interview with S1 revealed they change R1 “about twice a night” and S1 if often sleeping at night and does not wat to be bothered. Interview with Staff #3 (S3) at 2:50 p.m. on 03/06/2024 and Staff #4 (S4) at 3:00 p.m. on 03/06/2024 revealed they changed R1’s diaper as needed and checked on them every two (02) hours. Record review of shift notes from 12/07/2023 revealed R1 “refused to be changed if [they are] sleeping but we still check on her”. Shift notes from 12/20/2023 indicated R1 again refused to be changed due to sleeping. Based on interviews and record review, the facility provided proper supervision and incontinence assistance to R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.