Complaint Investigation Report

interviews with staff and the client in question; the client admittedly had not showered in the three months before moving into the facility. A source reported that the facility made numerous attempts to motivate or encourage the client to shower unsuccessfully. Interviews with outside sources close to the client were conducted. These sources did not witness the facility treat the client without respect nor were they informed by the client that the client was forced to accept meals and medications outside.

According to interviews and record review, a previous employee sent staff an email asking them to encourage the client to take meals and medications outside the main common area. Interviews revealed staff understood the strategy to represent motivation for the client to shower. None of the staff interviewed stated they forced the client to shower nor accept meals outside. Clients were interviewed. None witnessed this client or any client receive medications or meals outside. Client interviews consistently stated that the client refused to shower and the client's odor was offensive. In none of the interviews with staff and clients, nor the records reviewed, did LPA locate a reference to torture or punishment of the client for refusing to practice hygiene.

Based on further investigation and follow up interview, it was determined on one occasion the client agreed to receive their medication at the door leading into the facility. The location is directly outside and adjacent to the medication room. The area is covered and based on interviews, the weather was not inclement or cold. The client was asked if staff forced them to get their medications or meals outside and they said they were not. This client said staff treats them ok but are "bossy" at times.

There is sufficient evidence to indicate that on one occasion, a client was given medication outside the facility due to poor hygiene. Although, there is no evidence the facility's intent was to torture or punish the client or strip them of their dignity, the Department considers even the consideration of such a practice to be a violation of the client's personal rights.

Based on interviews, a preponderance of evidence exists to show that the facility gave a client medication outside the facility on one occasion. The allegation is Substantiated. A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Jennifer Melcher, to whom a copy of this report, the LIC 9099D, and Licensee/Appeal Rights (LIC9058 03/22) were provided.