Complaint Investigation Report

9099C(1)..Resident (R1) moved into the Memory Care Unit of the facility on/around August 10, 2021 from a skilled nursing facility. Resident’s physician’s report, dated 7/29/2021, indicates resident has a diagnosis of Dementia, Type 2 Diabetes, has auditory impairment, is able to participate in bathing and needs assistance with toileting.

Allegation: Resident did not receive a shower chair for a long period of time. Complaint states that resident did not receive a shower chair for months.

Staff interviews revealed that resident had a shower chair upon moving into the community in August 2021 and that the chair actually belonged to resident's roommate but she was able to use it. Fax communication to resident’s physician, on 9/26/2021, notes resident had a “guided fall” while being assisted in the shower as resident was sliding down in the chair when she began screaming and kicking staff members.

Staff interviews also indicated that when resident moved to another room on/around March 2022, she did not have a shower chair to use for a while and so staff had to try and shower resident while she was in her wheelchair. Another staff state d that she saw a chair in resident's personal shower at one point but then it disappeared, so she checked in the laundry room and the chair was not there. A third staff stated on 5/24/22 that staff was "still trying to get the doctor to fax an order- she is not using one that I know of". Physician Fax reports show a request for an order was made for a shower chair on 4/19/2022 and 4/27/2022. A fourth staff stated resident was "always scared to stand up" and she had a chair and "we used her wheelchair " also and sometimes it took (2) of us to shower her. Staff stated resident got a shower chair in September 2022.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED-

Allegation: Resident developed a rash while in care. Complaint alleges client has rashes on her breast and stomach and smells very bad.

All staff interviewed indicated that resident was challenging to give a shower to and would often resist staff trying to bathe her. Several staff stated that resident would go weeks without a shower due to not liking the water with one staff stating " she never got showered" and "constantly had a rash under her breast".