Complaint Investigation Report

It was alleged that the facility retaliated against R1 by adding additional unnecessary and non-medical care for R1, which was duplicative of the care provided by the facility’s staff and charged R1’s responsible party without their approval.

The investigation revealed that R1 was admitted to the facility with a foley catheter and subsequently had surgery to replace insertion of the foley catheter with a suprapubic catheter. R1’s Medical Records document that R1 needed daily cleaning and bandage changes for their suprapubic catheter, which must be performed by a skilled professional. However, R1’s Home Health Records and interviews revealed that this skilled care was provided approximately twice a week. The facility advised R1 that their needs were not being met, they needed a higher level of care, and that one-on-one supervision would be required. R1’s family believes the requirement of one-on-one supervision was retaliation due to issues they had raised with the facility. However, the facility’s policy and R1’s Admission Agreement indicate temporary one-on-one supervision would be instituted at the resident’s expense when it has been determined that a resident needs a higher level of care. The facility retained an outside agency to provide one-on-one supervision to R1, but the service was never provided as R1’s family refused and obtained their own private caregiver.

Based on gathered information, R1 requires a higher level of care, due to their suprapubic catheter which required daily cleaning, bandage changes and frequent showers. In addition, R1 required additional supervision to prevent R1 from picking at their catheter site, which was observed to be red and irritated. There is no evidence to support that these care requirements were imposed in retaliation.

Based on LPA’s observation, interviews conducted, and records reviewed, there was not sufficient evidence to support the above allegations. Although the allegations 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 deemed UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report was discussed with and provided to facility representative.