complaint·July 7, 2025

***CONTINUE FROM 9099*** LPA reviewed email correspondence from W1 documenting multiple attempts since January 2025 to address concerns regarding R1’s catheter care. W1 stated she observed through a camera that the catheter bag was often full and discolored. On 03/11/2025, R1 was taken to the ER due to lack of urine output and diagnosed with a severely distended bladder. Per W1’s email dated 03/12/2025, the hospital removed “a large amount of urine” from R1 and recommended changes to prevent recurrence. In another email dated 03/28/2025, W1 shared that her home health nurse discovered the catheter had become disconnected, with urine draining into R1’s clothing, which was wet upon her arrival. Interviews with S2,S3 and S5 revealed that while staff were aware of the catheter, monitoring duties were not clearly assigned during overnight shifts. S5 noted that catheter issues were often identified by home health, not staff. LPA reviewed progress notes and MARs and did not find consistent documentation of catheter care checks. W1 expressed concern that staff contacted her while she was out of the country instead of the 24/7 home health service listed in R1’s file. Based on W1’s evidence, lack of documentation, and interviews confirming inconsistent practices, this allegation is substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted, a copy of this report and appeal rights provided.