Complaint Investigation Report

The investigation revealed the following:

Regarding the allegation “Staff did not check on resident every 2 hours for incontinence care”, it is being alleged that Resident 1 (R1) was not assisted with incontinence care on 10/15/2024 from 2:00 AM to 6:00 AM. Interviews conducted revealed the following: 5 out 5 residents indicated that staff does not check on them or assist them from 2:00 AM to 6:00 AM. 4 out 5 residents indicated that there is no night staff. R1 indicated that she was not assisted with incontinence care at night. 3 out of 3 staff indicated that they do not work from 2:00 AM to 6:00 AM. 3 out of 3 staff indicated that their “Daily Time Sheet” is correct. Records reviewed of Daily Time Sheets revealed the following: “Daily Time Sheet Caregiver 1” “Covered Dated Oct. 1-15, 2024” demonstrates that Caregiver 1 works from 7:00 AM to 7:00 PM; according to the time sheet Caregiver 1 worked on 10/15/2024 from 7:00 AM to 7:00 PM. “Daily Time Sheet Caregiver 2” “Covered Date” Oct. “1-15, 2024” demonstrates that Caregiver 2 works from 8:00 AM to 8:00 PM; according to the time sheet Caregiver 2 worked on 10/15/2024 from 8:00 AM to 8:00 PM. “Daily Time Sheet” for Caregiver 3 “Covered Date Oct. 1-15, 2024” demonstrates that Caregiver 3 works from 8:00 AM to 8:00 PM; according to the time sheet Caregiver 3 did not work on 10/15/2024. Resident 1’s records revealed the following: “Physician’s Report for Residential Care Facilities for the Elderly” indicated that R1 needs incontinence assistance; “Resident Appraisal for Residential Care Facilities for the Elderly” states “Services Needed” with incontinence care; “Appraisal/Needs And Services Plan” states “Physical/Health: Incontinent, Provide Assistance on their Toileting Needs, Time Frame: Length of stay, Method of Evaluating Progress: Daily Observation and Monitoring”; “Admission Agreements for Residential Care Facilities for the Elderly” states that R1 will be receiving assistance with “toileting” and “other personal care needs.” Regarding the allegation “Staff did not check on resident every 2 hours for incontinence care”, the preponderance of the evidence standard has been met therefore the allegation is substantiated.