Complaint Investigation Report

Regarding allegation “Facility staff are not providing incontinence care as needed” it was reported that during the nocturnal (NOC) hours, staff are not checking on residents regularly, leaving them soiled for extended periods of time. An interview with the Marketing Director revealed that night and NOC staff have been reporting to work as scheduled and they have not received formal complaints from residents regarding un-met incontinence needs. Interviews with the morning (AM) staff indicated that residents are often found soiled at the beginning of their shift and have expressed frustration about waiting for long periods before receiving assistance after activating the call light system. NOC staff denied the allegation, stating that all required checks and incontinence care are being provided as scheduled. Resident interviews, however, revealed consistent concerns regarding staffing levels during all shifts. Several residents stated that it is difficult to receive timely assistance at night and that staff do not check on them as frequently as needed. Some residents reported feeling neglected and described instances where staff where “nowhere to be found” when they were wet and soiled and assistance with incontinence care was required. One resident in particular, Resident #1, reported activating the call cord for restroom assistance and waiting approximately 40 minutes without receiving help. Eventually attempted to get up independently, lost balance, and sustained a fall that required hospitalization. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Facility staff are not providing incontinence care as needed” has been SUBSTANTIATED at this time.

Regarding allegation “Staff sleep while on duty” it was the reporting party’s concern that Nocturnal (NOC) staff sleep throughout their shift, resulting in residents not being monitored, rounds not being conducted, and residents not receiving assistance during the nighttime hours. NOC staff denied the allegation, stating that required rounds and resident checks are being conducted as scheduled. Interviews with residents revealed that it is difficult to receive timely assistance at night and that staff do not check on them as frequently as needed. Some residents reported feeling unattended and that staff are frequently not present or available when assistance was required.