Complaint Investigation Report

Allegation: “Resident is left soiled for an extended period of time:”

The complaint alleges that R1 was not changed regularly. Review of R1’s physician’s report indicates that R1 does not have a bowel or bladder impairment, but that R1 is unable to care for their own toileting needs. The needs and service appraisal provided to LPA was incomplete and missing the pages related to incontinence care and assistance with toileting. Staff interviewed indicated that R1 requires assistance getting to the toilet and assist in changing R1’s briefs if needed by putting the briefs at R1’s ankles for R1 to pull up on their own. R1 utilizes the call light system when R1 requires toileting assistance. Staff stated that R1 regularly uses the call light and staff respond accordingly to assist R1. At the time of the initial complaint visit, R1 was hospitalized, and Administrator indicated that R1 only returned to the facility for a day or two prior to moving out of the facility. LPA attempted to reach R1 via telephone but LPA was unsuccessful. During an unrelated complaint visit on 04/05/2023, LPA observed staff assisting R1 in the restroom during the visit. Other residents interviewed felt their incontinence needs are being met and staff assist with toileting. Based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “resident is left soiled for an extended period of time” is deemed UNSUBSTANTIATED at this time.

Allegation: “Resident has missed meals due to staff neglect:”

LPA conducted interviews with staff and residents related to this allegation. Staff indicated that R1 used to consistently go to the dining room for all meals. Recently, R1 has been experiencing pain and does not wish to get out of bed in the morning to go to the dining room during breakfast hours. Staff stated they are bringing R1 room trays for breakfast for the last 2 (two) weeks or so instead. Care staff interviewed indicated kitchen staff prepare the trays, then the care staff bring R1 their room tray and they are not aware of a time when R1 did not get fed. Staff interviews revealed that R1 prefers hot breakfast, which is difficult as R1 does not get out of bed to eat until 10:00AM or 11:00AM and that breakfast is served at 07:00AM. Staff stated they bring oatmeal and juice to R1 and if R1 prefers a different choice, they will return to the kitchen and ask for an alternative. According to staff, R1 chooses not to eat lunch sometimes, per their preference. R1 reportedly told staff that they prefer to eat breakfast in the late morning, then they eat dinner in the dining room, with just a light snack in between when hungry. Staff indicated that when dining staff did not see a resident in the dining room, they prepare snacks for that resident, in case they were needed. LPA was