Complaint Investigation Report

On today's visit LPA Yee conducted additional interviews. LPA conducted interviews with Virginia Sumulong, Assistant Administrator at 11:50am, Staff #1 at 12:37pm and the Executive Director at 3:36pm and reviewed and obtained additional facility files throughout the visit.

Per information received regarding Allegation #1 - Resident sustained pressure injuries while in care, the investigation revealed that the resident was observed with a open wound on their coccyx on 11/28/22 and a scar between the buttocks. The wound was cleaned, treated with incontinence cream, resident was re-positioned to take pressure of the wound and a home health referral was requested. Per review of hospice records, Resident #1 was receiving wound care and the nurse notes "in addition to poor circulation, neuropathy and difficulty moving, factors that contribute to chronic wounds include systemic illness, age and repeated trauma. Patient was instructed on factors that may contribute to chronic wounds is old age. The skin of older people is more easily damaged, and older cells do not proliferate as fast and may not have an adequate response to stress in terms of gene up regulation of stress related proteins." Incontinence may have been a contributing factor but there is no conclusive evidence that it was sole reason for the cause of the pressure injury. The report does not indicate that the wound was the result of neglect on the part of facility staff. Staff interviewed deny that residents are left unattended for long periods of time in their soaked diapers. This may or may not have happened, but there is no preponderance of evidence to conclusively say it was neglect on the part of the staff's failure to timely change the resident. Therefore, allegation is UNSUBSTANTIATED at this time.

Investigation into Allegation #2 - Staff do not meet resident's incontinence needs, per Staff interviewed, incontinent residents are checked every 2 hours or 1 hour if they are observed to get wet more frequently or when they pull the signalling system. The signalling system is monitored in the front office and staff is sent to change the resident. There are 3 caregivers on schedule for the first two shift and 2 on the night. If one caregiver is helping a resident, the next available staff will handle the call. Per staff interviewed, if someone calls out and there is not staff available to do overtime, they use agency staff. Per the investigation, it may or may not have happened, but there was no preponderance of evidence to support the allegation that the staff do not meet the residents' incontinence needs therefore, the allegation is UNSUBSTANTIATED at this time.