Complaint Investigation Report

The Administrator reported they reported the issue to R1's responsible party. W1 reported that they never witnessed any abuse by the staff toward any of the residents. The cause of the scratches on R1 is unknown.

LPA interviewed R1's physical therapist who reported they have never witnessed any type of abuse at the facility. 2 out of 5 residents interviewed reported they have never witnessed or experienced any abuse from staff. 3 out of 5 residents did not respond to LPAs questions and could not be interviewed. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff do not follow resident's care plan, revealed the following. It was reported that R1 was not assisted with their incontinence and not changed as often as listed in their doctors orders and R1 is to be kept upright for 10 to 15 minutes after taking medication and drinking liquids. The Administrator reported that the care plan is based off of doctor's orders and no such orders were provided. A review of records shows the only doctor's orders provided are for R1 to be rotated every 2 hours to assist with blood flow, prevention of pressure injuries and to check every 2 hours for incontinence to ensure proper hygiene to minimize pressure injuries. The Administrator reported that R1's responsible party asked them to keep R1 upright after taking medications and drinking liquids for 10 to 15 minutes but they never provided a doctor's order so they didn't do it. 4 out of 4 staff reported that R1 was checked every hour and changed at least 3 times a day and whenever required to ensure they were clean and to minimize any skin breakdown. R1's responsible party reported they had additional doctor's orders but they were not provided to the LPA and they could not explain why they weren't provided to the facility. The Administrator reported they follow all doctor's orders and attempted to work with R1's responsible party but they did not receive a response. R1's responsible party could not explain why they didn't respond to the Administrator. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff leave resident in wet diapers for extended periods of time, revealed the following. It was reported that R1 was left in soiled briefs for extended periods of time. No specific details were provided as to the date or time when this occurred.