Complaint Investigation Report

Staff #8 (S8) had marked in the Medication Administration Records that medication was provided. S8 also conducted 2nd medication check as well. Based on record review, the allegation Staff mismanaged resident’s medication is substantiated as the facility self reported the incident.

Allegation #2 Resident's diapering needs were not met.

It was alleged that staff were not changing Client #1’s (C1) diaper after C1 soiled diaper. The reporting party stated that there was a day when C1 was found wearing soiled diaper. This incident occurred as staff shift was changing. The reporting party also reported that C1’s room and bed had smearing of feces. LPA interviews reveal that C1 has reached into C1’s diaper with C1’s hands to check if diaper had been soiled. As a result, C1’s hands would be dirty, and C1 would run hand along various surfaces such as walls, bed, and other body parts. Interviews among staff reveals that C1 is able to communicate when C1 has soiled self. Staff would assist C1 in changing into fresh clothing and diaper. Staff are also able to identify when C1 has dirtied self through smell and observation.

LPA reviewed Therap Logs from August 2020 through November 2020. Logs do not report that C1 displayed this behavior of reaching into diaper. Therap Logs mentions few cleaning after C1 but does not specify the events surrounding the cleaning. Therap Log for 8/3/20 2-10 p.m. shift reported, “This staff left the med room with C1’s afternoon medication shortly after 3 pm. This staff located C1 in the restroom. C1 was undressed sitting on the toilet. No staff was present. C1’s clothes and underwear were on the floor. A large amount of feces was observed by this staff inside the underwear. C1 had dried stool smeared on C1's face, on C1's fingers and hands, on C1's back, and in C1's peri area. The stool was dried on parts of C1's thighs, legs, and feet. This staff cleaned up C1 up as C1 spit, hit, and kicked at this staff numerous times.” It should be noted that prior shift was a 6 a.m.to 2 p.m. and would be responsible for assisting clients cleaning up after waking up. C1 will wear a diaper overnight but not during the day. It is unknown how long C1 remained in current condition when p.m. staff found C1. Therap log entry 11/29/20 2-10 p.m. shift reported " was good all day. dont know if C1 is getting sick or not but C1 was asleep when i got to work at 2 and then C1 slept almost the whole day C1 woke up around 830 C1 had poop in C1 diaper so i changed C1 sat C1 on the toilet and C1 pooped again i cleaned C1 up and got pjs on C1." It is not reported which shifts C1 will wear a diaper. Other entries reports staff do clean after C1. Based on Therap log entry for 8/3/20 2-10 p.m. shift, the allegation Resident’s diapering needs were not met is substantiated.