Complaint Investigation Report

Per record reviews and interviews, C1 has a Case Manager (CM) with the County, who is in contact with the facility and the client regularly, and as needed. Per interviews with staff, S2, S3,and S4, the client (C1) would not want to shower and get cleaned up and/or change their clothes as needed, but staff would continue to ask C1 to shower, and sometimes they could get the client to, and other times it wouldn't be until the next day. Staff S3 stated they would tell the client they needed to shower so they can be clean because C1 was having a bad odor. S3 stated we staff tell C1 and they wouldn't want to shower, and go back later and ask again, and C1 will shower. S3 stated this is what we had to do. S4 stated that they saw C1 on the flloor on 1/13/24, and called S2 to help them get client (C1) up. S4 stated they helped C1 shower because they had urine and feces on their pants area, clients pants had fallen down when they fell. S2 assessed the need to call 911 for C1 to be medically assessed due to the client not responding well to S2's questions. Staff stated they had not observed the client C1 to have falls, and staff stated that C1 walked slow but did ambulate on their own. Staff stated they have not seen the client bruised all over; S1 stated that C1 smokes constantly, and always coughs on the cigarette smoke. S1 stated that if C1 had any falls they were not observed, and staff were not told or aware of it. S1 stated that they call 911 as needed, and responsible party, including the Doctor. S1 stated that they had told the case manager (CM) that the facility is for ambulatory only, and the client should be placed in higher level of care if health care needs have changed since the fall of 1/13/24. S1 stated the CM made the decision to place the client in a facility with a higher level of care. Per interviews with other related parties, C1 didn't like to shower or change clothes. Staff would remind C1 about getting showered. C1 could walk around on their own, they were just slow at it. There was no information obtained during the investigation to support a violation had occurred regarding the allegation.

Based on the interviews, record reviews, and related information obtained during the investigation, the allegation of “severe neglect/lack of supervision" of the client C, is Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Exit interview was conducted with the Lead Caregiver Danilo Galicia.