Complaint Investigation Report

Allegation: Staff left resident in a soiled diaper for an extended period of time

During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). Review of R1’s timeline of issues at the facility showed R1 engaged in inappropriate behaviors towards staff and disturbed other residents from 05/08/22 to 10/23/22. This included R1’s refusal to allow staff to change his soiled brief on the following dates – on 08/02/22 R1 refused to allow staff to change his brief stating he wanted police to change him (R1 called 911); 08/21/22 R1 refused to allow his soiled brief to be removed by staff and preferring it to be left on the floor so police could see it (R1 called 911); 09/18/22 R1 refused to allow care team to change his soiled brief and blew a whistle when he was brought to the lobby disturbing other residents. On 10/09/22 and 10/12/22, R1 refused to allow staff to change his soiled brief and clothing, was verbally abusive to staff, attempted to kick staff and called 911 stating his care needs are not being met. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation staff left resident in a soiled diaper for an extended period of time was found to be unsubstantiated.

Allegation: Staff did not respond to residents call button in a timely manner

During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). ED stated R1 has dementia who kept his call pendant light on 24/7. Staff (PD) witnessed R1 hit/scratch care staff, used foul language towards caregivers on 07/21/22, wouldn’t allow them to reset his call pendant, swung a broom at staff on 08/23/22 and would constantly call 911 stating staff was intentionally trying to harm, poison and kill him. On 09/17/22 R1 refused care team and would not allow them to reset his call pendant. ED stated R1 would constantly call 911 stating care staff was not attending to his needs. On 09/18/22 R1 refused to allow staff to change his brief and was brought to the lobby with whistle and created disturbance. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation staff did not respond to residents call button in a timely manner was found to be unsubstantiated.