Complaint Investigation Report

Behavior Plan at a Glance dated 04/04/2024, Twin Cities Community Hospital Discharge dated 05/12/2024 and all forms were current. The facility is keeping up with all plans to provide R1 the best possible care with the refusal behaviors at this time.

On the allegation: Facility staff do not meet resident’s incontinence needs. Based on interviews the staff at the facility do change R1 several times a day, use wipes to clean R1 and sponge bath R1 daily. The staff have not been able to get R1 to take a shower due to R1's refusals. The staff have tried different times of the day and different staff asking R1. R1 is only allowing a few staff to help R1 and it has been by wipes or sponge bathing. R1 used to use the restroom but R1 has been incontinent wearing briefs now since November of 2023. R1 had a recent 911 ER visit due to staff coming on shift worried about R1 and that R1's refusals may have lead to sores and or sepsis. R1's discharge from the ER did not have any notations in regards to neglect, sores or sepsis. The discharge diagnosis was Abdominal Pain with Diarrhea and a follow up appointment with Primary Care Physician (PCP) was requested. R1 has an appointment on June 6, 2024 at 2:15pm which was the soonest staff was able to get R1 in to see PCP. Tri-Counties Regional Center (TCRC) placed R1 at this facility in 06/2023 and the facility has had meetings with TCRC about R1. The most recent team meeting regarding R1 was held 05/01/2024 with facility Administrator, R1, TCRC and Behaviorist. Everyone is aware of R1 and the refusals to shower. The facility is currently working with TCRC on placement for R1. Based on the evidence this allegation is Unsubstantiated at this time.

On the allegation: Facility staff do not ensure resident's hygiene needs are being met. Based on staff interviews R1 has been refusing showers. R1 is being changed several times thorough out the day. R1 is getting wiped down daily and R1 is getting sponged bathed Monday-Friday on a regular basis. R1 was showered recently on Noc shift early morning on the 12th by staff 5 (S5), R1 would not allow for R1's hair or face to be washed but allowed S5 to use a washcloth to clean R1's body, R1 was also given a wash cloth to help clean R1's self. Staff at the facility called 911 and R1 went to the ER later that afternoon on the 12th, the staff that came on duty felt R1 had not been cleaned since the prior day and was worried that R1 would have skin breakdown, sores and or sepsis. The discharge paperwork was reviewed by LPA and had no mention of neglect, sores or sepsis. The ER diagnosis was abdominal pain. The facility staff are working with TCRC and Behaviorist to help R1 with R1's changing behaviors.