Complaint Investigation Report

Interviews with R1’s physician and review of medical records revealed that R1 was treated for a urinary tract infection (UTI), sepsis, and kidney problems. During R1’s hospitalization, R1 had a foley catheter inserted. R1 was discharged back to the facility after a stay in a skilled nursing facility (SNF) on 1/11/2022. Interviews with staff and outside sources revealed that staff used a device called a Hat device which is placed in the toilet to check a resident’s urine output, ensure residents are consuming enough fluids, and to collect urine for medical samples. R1’s physician stated that R1 had a history of UTIs and sepsis and R1 retained urine and was not able to fully empty their bladder which increased R1’s chances of getting a UTI. R1’s physician stated that it is common for symptoms of UTI to not appear until the infection worsens.

On 1/27/2022, staff assisted R1 to the toilet and observed R1 with a prolapsed organ. R1 was transported to the hospital where R1 received surgery for a prolapsed rectum which resulted in a colostomy bag. R1 was discharged back to the facility on 2/16/2022. Interviews revealed that R1 was a private individual and preferred for staff to assist R1 to the toilet and leave R1 on the toilet until R1 used their pendant to call staff when R1 was finished using the toilet. Interviews with staff revealed that R1 would sometimes sit on the toilet for 20-30 minutes but staff would check on R1 after about 15-20 minutes if R1 had not called for assistance. Interviews with R1 revealed that R1 was happy with the care provided by staff and there were a few occasions where R1 felt like staff had left R1 on the toilet for too long. R1 stated that those occasions were due to staff being busy with other residents. Interviews with residents revealed that they felt comfortable and happy with the care provided by staff and while staff were busy, they would respond promptly when residents needed assistance. Interviews with outside sources revealed staff were attentive to resident requests. Interviews with R1’s physician revealed that being left on the toilet for too long could not directly be attributed to R1’s prolapsed rectum. R1’s physician stated that R1 had occasional constipation and pushing when having a bowel movement could contribute to a prolapsed rectum. R1’s physician stated that a prolapsed rectum can occur suddenly or over time, but would be painful and R1 would have complained about pain if it had occurred over time.

The Department has investigated the above-mentioned allegations and based on interviews and record review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Executive Director Charles Bloom, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.