Complaint Investigation Report

On 8/19/2021, the Department interviewed R1's family member (FM). FM stated R1 was not incontinent. FM stated he/she wanted R1 to wear fresh/clean undergarments daily, so he/she brought a lot of diapers in R1's bedroom, and he/she changed R1's diaper whenever he/she met R1. FM stated most of time he/she found R1 wore soiled diaper whenever he/she visited R1. FM stated he/she found caregivers did not change R1's diaper often. FM stated the resident bedroom trash bags were changed 2 or 3 times per day, why the facility was unable to change R1's diapers at least 3 times per day. FM admitted R1 did not participate in the facility changing diaper program, because R1 did not need to change diaper every two hours.

On 8/20/2021, LPA interviewed Executive Director (ED). ED stated that upon admission, residents were assessed if the residents need the toilet remind or need physical hands-on changing diaper. If there was no need for the service, then the facility will not check or change the residents diapers. ED stated if the assessment shows the resident needs the service, then the resident needs to pay either $400/month fee for toilet remind service or $900/month fee for hands on diaper changing service. ED stated the facility will check resident diaper every two hours for the services. ED stated R1 was not diagnosed as incontinent and was not evaluated as toilet reminding needed or diaper changing needed. ED stated R1 did not have toilet reminding or diaper changing in R1's care plan. ED stated caregivers provide care service according to care plan, so R1 did not receive the service of diaper changing. ED stated caregivers changed R1's soiled diaper when caregivers found R1's diapers needed to be changed. ED stated residents can participate in the toilet reminding or diaper changing programs voluntarily if they pay the fee. ED stated the facility communicated with R1's family member to have R1 participate in the changing diaper program, but R1's family disagreed to pay $900 per month. ED stated housekeepers cannot change residents' diapers.

Reviewing R1's medical documents, R1 was not diagnosed incontinent and R1 was not evaluated to have toilet reminding or diaper changing service. FM found the diaper supplies he/she put in R1's bedroom decreased but did not decrease as much as expected that means caregivers changed diapers for R1 but not as often as needed. FM did not pay the monthly fee for the changing diaper program. The facility suggested R1 to participate in the changing diaper program, but FM disagreed.