Complaint Investigation Report

Regarding the allegation that Staff do not meet a resident's catheter needs while in care , the following has been concluded: Per a review of resident R1's transitional information gathered prior to R1's move-in on October 30, 2024 as well as a review of R1's physician report and pre-admission appraisal, it is indicated that R1 moved into the facility with a foley catheter already in place. The transitional information indicates that the resident's plan of care calls for the foley bag to be emptied once it reaches a third to a half of its full capacity. Based on photographs provided by witnesses dated January 14, 2025, there have been instances during which the foley bag was not emptied timely as foley bag appeared to be almost full at the time of the photograph being taken. Another instance of the catheter bag not being emptied overnight was found upon a review of R1's chart for May 2025. R1 had a documented history of urinary tract infections prior to their admission at the facility, therefore it is unsure whether the catheter management is related to any active infection occurring.

Per statements made by facility staff during the initial investigation visit, an in-service regarding catheter care and perianal care was conducted after the incidents evidenced above.

As a result, the allegation is found to be Substantiated, meaning that based on the evidence gathered during this investigation, the preponderance of evidence standard has been met. A corresponding deficiency is being cited on the attached form LIC9099-D.

An exit interview was conducted with facility staff. A copy of the report along with appeal rights were provided.