Complaint Investigation Report

Allegation: Staff left resident in soaking wet clothing for extended periods

The details of the complaint alleged that facility staff are leaving residents in soaking wet clothing for extended period of time.

During the records review, LPA received and reviewed the Resident Incontinent List and reviewed Resident Physician’s Report, Pre-Admission Appraisal, Needs and Service Plans, Staff Notes for the past 5 months and Admission Agreement.

During interviews with staff (S2-S12), were asked if a resident has been left in soiled diapers or clothing for an extended period of time, eleven (11) out of eleven (11) stated they have not seen nor heard of any residents being left in soiled diapers or clothing for an extended period of time. Additionally, staff S2-S12 were asked how often incontinent residents are changed, nine (9) out of eleven (11) stated they are checked every two hours, one stated when needed, and one stated on a regular basis.

During interviews with residents (R1-R6), were asked if they have been left in soiled diapers or clothing for an extended period of time, five (5) out of six (6) stated they have not been left in soiled diapers or clothing for an extended period of time and they are assisted right away.

During the visit, the department interviewed five (5) family members of residents living in the facility (spouse or children). During interviews with witnesses W1-W5, were asked if there has been a time their family had been left in soiled diapers or clothing for an extended period of time, four (4) out of five (5) stated they have not been told or observed their family being left in soiled diapers or clothing. One witness stated that was an issue they experienced 5 months ago, and there have been no issues with it recently.

During the investigation, the department did not find sufficient evidence to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard was not met. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Allegation: Staff mismanaged residents’ medication

The details of the complaint alleged that facility staff have given the wrong medication to residents.

During the records review, LPA reviewed the facility’s electronic Medication Administration Record (eMAR) and compared it to the centrally stored medications for 10 residents. LPA observed ten (10) out of ten (10) resident’s eMARs and medications are consistent with properly documented records. LPA reviewed Special Incident Reports (SIR) submitted since October 1, 2023, and did not observe any SIRs reporting a medication errors.