Complaint Investigation Report

Allegation: Staff do not ensure that resident's incontinence care needs are met. It is alleged that staff did not meet the in continence needs of bed bound resident (R1). According to reporting party, facility staff were not changing R1's incontinence diaper, resulting in the resident lying in urine and feces. On 11/20/2023 and 12/8/2023 R1 requested incontinence care assistance via call light system. Staff checked on the resident, but stated they would be back to change R1's diaper and never did. On 12/8/23, an attempt was made to communicate R1's needs/staff neglect to staff (S2), but staff stated "I can't talk right now".

Resident (R1) was interviewed and stated that staff allege that the resident refuses to be changed, but that is not the case. The resident stated that sometimes staff came in to the room to change the diaper, while the resident was in the middle of a bowel movement. Therefore, R1 often asked staff to come back in a short while once they are done with their bowel movement, but staff failed to return in a timely manner. Resident (R1) stated that staff "seem to come in to check on me every 3 hours or so", and feels staff are neglectful in meeting incontinence needs. Third party providers have found R1 with dirty diapers. Photographs were obtained. A total of 7 residents were interviewed; none reported issues with incontinence care.

A total of seven (7) staff were interviewed. Staff stated that R1 requires a 2-3 person assist when Hoyer lift is used because the resident is heavy. According to staff, R1 can only rotate themselves to the left side, but is distrustful of staff when repositioning during incontinence diaper changes. Staff stated that R1 gets anxious and is afraid staff will drop the resident when using the Hoyer lift. All caregiver staff interviewed stated that R1 sometimes refused to be changed or rotated, and they did not know if the resident had feces or was wet. According to caregiver staff, they have been instructed to change the resident only when there is a bowel movement, since the resident urinates on a urinal. Staff acknowledged that they have observed urine spilled on the floor and feces on chux pads. According to Administration staff interviews, staff are to report when a resident refuses incontinence care. However, facility was not able to provide documentation (Personal Continence Log) of R1's incontinence care refusal. In addition, staff confirmed that Hoyer lift in R1's room has broken down several times. Third party provider photographs were obtained. On 12/19/23, LPA smelled urine upon entering R1's room, and observed urine on the floor next to the urinal container. There is sufficient evidence to prove the allegation.