Complaint Investigation Report

Allegation 2: A video submitted by the complainant did not reflect the allegation of “yanking” or staff being “rough” causing an injury(ries) to R1. The video, was of a caregiver on 11/01/22 at 0456 hours removing the diaper from R1, who was lying on their back in bed. The caregiver pulls the diaper from underneath R1 until the diaper is pulled away from R1's body weight. Although the technique is questionable, it was not observed to be pulling or “yanking,” or any forceful action by the caregiver.

Allegation 3: The physician's report stated resident had impairment of bowel and bladder, continuous bed care with frequent repositioning, and a history of stage 2 pressure ulcer to sacrum. Care of Plan: Staff will check every 2 hours for continence and as needed. Staff training was conducted with the CNA caregiving staff on proper techniques for changing incontinence for residents.

Allegation 4: In regards to the unexplained injuries, it could not be determined how the injuries occurred. The St. Paul’s Plaza Executive Director and Director of Nursing were interviewed, as well as outside sources. The numerous photos also include two photos of R1's knees. The photos are not timestamped. The knees appear to be slightly red with possible light bruising. The “injuries” do not appear to be significant, if they are “injuries.”

Allegation 5: R1 required a special diet "thin liquid via straw, NTL via straw prn. Dietary changes due to pocketing food. R1 was to consume 75-100% of meals with no signs or symptoms of aspiration goal date was 03/08/2020. Residents interviewed confirmed they received three meals a day plus snacks. Staff interviewed stated that three meals per day are served plus snacks which included puree diets, mechanical diets, regular diets, and pescatarian diets. Certified Nursing Assistants (CNA's) served snacks to residents prepared by kitchen staff. There were no instances were staff did not provide R1 dinner.

Based on the investigation findings, it is concluded that the allegations: Facility staff did not properly assist resident causing resident to fall and sustain an injury(ries); Facility staff handled resident in a rough manner causing an injury(ries); Facility staff did not provide incontinence care resulting in skin breakdown; Resident sustained unexplained injuries; Facility staff did not serve resident dinner are unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted; a copy of this report along with Licensee Appeal Rights LIC 9058 (REV 3/22) were provided to the Assistant Administrator and her signature confirms receipt of these documents.