Complaint Investigation Report

9099C-1.. Allegation: Staff left resident in soiled briefs for extended period of time. The allegation states resident (R1) has been found in heavily urine soaked briefs, on several occasions, and (R1) had to have been left in soiled briefs for at least four hours. The allegation states caregiver states that R1 wouldn’t let them change (R1).

Resident's (R1) physician reports (9/14/22) states resident has a diagnosis of Dementia. (R1's) care plan, dated 3/22/24, notes that (R1) demonstrates anxious, disruptive or obsessive behaviors, and hospice notes indicate (R1) began receiving hospice care in December 2023.

All facility staff interviews revealed resident (R1) can be resistant to care. The Administrator, at the time, stated multiple approaches have been tried to get (R1) to do care with staff. The Resident Care Coordinator (RCC) stated (R1) is "checked every 2 hours but there are times when she is physically aggressive with staff and staff has to leave the resident alone", explaining (R1) will "push and scream", mostly when she is being changed, so staff will return in 10 minutes and try to provide the care again. The RCC commented that after 2-3 attempts, staff can try PRN Lorazepam- sometimes (R1) will take it and it works, but if she doesn't take it, it takes 2-3 caregivers to change her.

One lead staff stated (R1) is very particular with receiving assistance with Activities of Daily Living (ADL's) and about not being touched, adding (R1) has "soaked through her Depends" as she "will refuse toileting at least once a week". Two additional staff stated it takes two staff to change (R1's) diaper or clothes, or get her in the shower, as (R1) is "combative and will try to hold (keep) her pants on". One of the staff stated they will notify the Med-Tech if a resident won't let staff change them, and staff will try again in 10 minutes, stating "putting things on is not the problem- it's taking them off".

One staff stated she has had to remind care staff to change (R1) before and when hospice visits (R1), stating she feels it is a combination of staff not attending to residents and being tired as some staff are working "double shifts and 6 days/week", adding "things get busy but we try to change residents every 1-2 hours". Interviews revealed (R1) is "totally incontinent now" since December 2023 and "won't even go in the bathroom now without screaming".