Complaint Investigation Report

Allegation: Staff did not follow physicians’ orders .

It was alleged that C1 was diagnosed with an infectious bacterium which would require a 10-day round of antibiotics and C1 would need to be quarantined to protect other clients in care. The staff member (S1) who took the resident to the doctor returned to the facility and informed facility staff that the client was now required to remain in their room until they could be seen again by a doctor and retested for the presence of the bacteria.

After reviewing C1’s medical records from the hospital and primary care physician, LPA found no documentation that C1 was directed to remain in quarantine, nor that C1 was diagnosed with any potentially hazardous bacterium. Four (4) of four (4) staff interviewed were all in agreement that they had no knowledge of the reasoning for C1 needing to be quarantined as no medical documentation was ever provided. LPA received a written letter from an additional staff member indicating the same information.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Allegation: Staff did not ensure resident's catheter care is performed by a skilled professional.

It was alleged that staff are unable to properly care for a resident’s necessary catheter. As a result of interviews conducted, it was discovered that C1 is primarily responsible for the care of their own catheter/bag. C1 is able to independently empty the bag once it is full and staff are trained on how to disinfect the bag when it is being changed from the day to night bag and vice versa. C1 has monthly appointments with their urologist for catheter line changes and irrigation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.