Complaint Investigation Report

The facility submitted Unusual Incident/Injury reports to CCL for review. The Unusual Incident/Injury report indicate that, on 11/20/2021 at approximately 7:45 PM, R1 was noted to have multiple loose bowel movements and weakness. The facility notified R1’s Responsible Party (RP) and was taken to the ER for further evaluation for UTI and positive for C-Diff. On 11/27/2021, R1 returned to the community with new orders and care plan was updated as needed. On 12/10/2021, R1 was not feeling well and notified the facility. R1 was transferred to the ER for further evaluation. R1 was diagnosed with UTI and C-Diff.

The Department reviewed R1’s past and current medical records. Medical records document R1’s past medical history of indwelling Foley catheter with recurrent UTI. R1’s admission agreement indicated R1 moved into the facility on 08/12/2021. On 01/19/2021, R1 was treated for UTI. Interview statement received from R1’s RP indicated that R1 has had UTIs throughout the year; however, not back-to-back and one after another in a short period of time.

The Department reviewed R1's service plan which indicated R1 needed assistance with grooming, toileting, medication management, bathing, and dressing. R1 received Home Health for Foley Catheter care. In-service training for Foley Catheter care was conducted on August 2021 and November 2021. According to service plan, staff is to assist R1 with catheter care and emptying catheter every shift. Assist with changing R1's catheter (only) from day bag to night bag as needed (3 times per day, every day). It was discovered through interviews with six (6) facility staff that care staff had followed service plan instructions.

This agency has investigated the above listed allegation. Although R1 was diagnosed with a UTI on multiple occasions while residing at the facility, the department was unable to determine if it was due to facility neglect. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation to be UNSUBSTANTIATED .