Complaint Investigation Report

Allegation #4: Staff are not meeting resident's hygiene needs.

Allegation #5: Staff are leaving resident in urine-soaked items for an extended period of time resulting in wounds and skin tears.

The details of this complaint alleged staff are not meeting resident #1 (R1)’s hygiene needs which includes leaving (R1) in urine-soaked diapers for a long period that resulted in wounds and skin tears. The complainant reported (R1) appeared to be unclean, had nails with fecal items, and had hair matted, dirty, and unkempt. The complainant claimed (R1) has not been changed for an extended period and had an extensive amount of urine, as an indication of (R1) not being changed regularly. The complainant stated (R1) that wounds and skin tears may contribute to poor and neglectful handling. The complainant did not have further details information on these allegations as to the dates, time, and staff involved.

The investigation revealed resident #1 (R1)’s Identification and Emergency Information LIC601 (dated: 08/23/22) and Admission Agreements for Residential Care Facilities for the Elderly (dated: 08/23/22), (R1) was admitted at Santa Fe Home II on 08/23/22. As outlined in (R1)'s Faith & Hospice & Palliative Care Inc Patient Profile (dated: 08/24/22) care services began on 08/24/22. (R1) voluntarily terminated residency at this facility on 09/20/23.

On 09/28/24, between 9:30 am – 1:07 pm, the Department interview (3) out (3) administrator (A1) and staff #1-#3 (S1-S3) denied these allegations. (A1) and (S1-S3) all confirmed that (R1) was under hospice care a home aide would come to assist with hygiene and grooming care. Hospice aides and nurses monitor vital signs and personal hygiene three times a week. The facility staff would step in when (R1) refused hygiene and grooming services from a hospice home aide. (A1) claimed that (R1) was entitled to (R1’s) personal rights. There were often when (R1) declined to receive assistance with hygiene and grooming care from staff. The staff is respectful of (R1’s) rights and has the right to refuse such basic services. (A1) and (S1-S3) claimed that (R1) was repositioned, monitored, or changed at least every two hours or as needed. (S1-S3) denied leaving (R1) in urine-soaked diapers for an extended period. (S1-S3) communicated even at night shift hours of 11 pm – 6 am there is a staff on shift to attend to (R1)’s incontinence needs.