Complaint Investigation Report

Multiple relevant parties reported to the Department that facility staff do not provide assistance with incontinence care and/or bathing. Interview with resident (R3) indicated that they do not receive assistance with incontinence care and they went 5 to 6 weeks without a shower when they were requesting to have a shower. R3 stated they were refused both due to being required to use a shower chair. Interview with ED indicated that the facility required R3 to obtain a shower chair due to 2 person assist transfers no longer being safe for resident. ED stated that R3 personally made the order for the shower chair and shower chair was not provided by the facility. ED stated that it took 30 days to obtain the first shower chair, in which resident refused to use due to being uncomfortable, and another 30 days to obtain a second shower chair that the resident was able to use. ED stated that R3 was originally admitted with the use of a hoyer lift, but R3 refused to use hoyer lift after admission due to being uncomfortable for resident. Resident Assessments dated 9/19/2022, 10/2/2022, and 11/20/2022 for R3 indicated that resident required a two-person assist with the use of a mechanical lift. Resident Assessment dated 4/13/2023 for R3 indicated that R3 “requires two-person physical assistance with transfers.”

LPA reviewed R3's Physician's Report for RCFE LIC 602A dated 8/8/2022 and observed R3 was in need of assistance with toileting and bathing. LPA reviewed R3's Preplacement Appraisal Information (LIC 603) and observed R3 is "unable to transfer unassisted" regarding toileting and needs services for bathing. LPA reviewed R3's Resident Assessments dated 9/19/2022, 10/2/2022, and 11/20/2022 indicating that R3 "requires stand-by assistance for toileting," and 4/13/2023 indicating that R3 "requires hands-on assistance with incontinence; gathering incontinence supplies, hygiene, and/or changing linen." Resident Assessments for R3 dated 9/19/2022, 10/2/2022, 11/20/2022, and 4/13/2023 all indicated that R3 requires hands-on assistance for all showering/bathing needs 1 to 2 times a week. LPA reviewed the facility’s shift notes from April 2023 to August 2023 and Staff Assignments by Month by Unit for R3 from May 2023 to August 2023. LPA observed only the morning of 6/1/2023 documented as having R3 receiving incontinence care for the month of June 2023. LPA also observed only 1 bed bath documented for 6/1/2023 for the month of June 2023. All other entries for June 2023 were blank and not documented as care given. Bed baths and showers for R3 were documented inconsistently for the months of April 2023 and May 2023, with some weeks not having any bed baths or showers documented.