complaint·January 24, 2024

Page 1 Staff are retaining a resident that requires a higher level of care. It was reported that Resident 1 (R1) has progressively declined over time, as expected, but RP has significant concerns because R1 keeps getting hospitalized for severe infections. LPA reviewed Resident 1’s (R1) LIC602 Physician’s report which shows a primary diagnosis of sepsis/UTI. Resident 1 (R1) stated they have a catheter and they have had a lot of trouble with it. R1 was in the hospital for 4 days in November 2023 and 3 days in the ICU in October 2023. R1 stated they get cellulitis in their left leg. During staff interviews it was learned that even though R1 requires a lot of care, R1 does get the care they need living at the facility. Executive Director stated that clinically R1 does not require a higher level of care. Facility staff are able to care for R1 and R1 has a right to be here like anyone else. There is no reason for R1 to go to skilled nursing. It was determined that R1 has a primary diagnosis of sepsis/UTI. Although R1 has been hospitalized on multiple occasions recently there is no evidence to support the hospitalizations were due to the resident requiring a higher level of care than can be provided at the facility. This allegation is unsubstantiated. Continued on LIC90990- C Page 3 Staff do not meet resident's toileting needs. It was reported that R1 requires a mechanical lift to get in and out of bed and on and off the toilet, sometimes R1 has to wait for a staff member to get back from lunch to use the restroom. LPA reviewed Resident 1’s (R1) Service Plan which states that R1 requires physical assistance with toileting and uses a sit-to-stand to transfer to and from the toilet. R1 stated that when they were hospitalized they were given iv antibiotics which gives R1 bad diarrhea and hospital staff did not attend to R1’s toileting needs in a timely manner. R1 stated this occurred at the hospital, not at the facility R1 lives in. R1 stated that facility staff use a sit to stand to assist R1 on and off the toilet and in and out of bed. Staff interviews revealed that staff typically assist R1 within 5 minutes of the call light going off. After meals staff help R1 on to the toilet and when R1 is done they tell staff and staff help R1 off within a few minutes. ED stated Staff use a sit to stand to assist R1 on and off the toilet and in and out of bed. Staff help R1 and R1 has transfer support assistance for safety. When R1 pages for assistance staff assist as soon as they can and if there is another incident happening at the same time staff check on R1 as soon as possible. It was determined that R1 may have experienced untimely toileting care while hospitalized, not at the facility they live in. This allegation is unsubstantiated. Continued on LIC90990- C Page 4 Staff are not adequately trained to assist with resident's catheter. It was reported that R1 has a bladder catheter tube that goes through R1’s stomach below the belly button and sometimes it seems like staff have not been properly trained to take care of it. LPA reviewed Resident 1’s Service Plan which states that R1 requires physical assistance with toileting including catheter assistance and trained staff will empty drainage bag once each shift and as needed if more than half full and PRN per R1s request. Plan also states Home Health nurse to change Foley catheter per Physician orders and PRN for inadvertent removal or occlusion. R1 stated that a home health nurse comes in and provides assistance with R1’s catheter and facility staff empty R1’s catheter bag twice a day. During staff interviews it was learned that care staff empty R1’s catheter bag but home health come in weekly to provide all other catheter care. Staff were trained how to empty R1’s catheter bag by home health, their supervisor or a Med Tech. ED stated R1 has a Foley catheter. Home health does the switching and changing of R1’s catheter. R1’s doctor or home health nurse removes and re-inserts the catheter monthly. We don’t do any part of that. Staff just empty the bag. Our Med Tech or home health train staff on how to empty the bag. It was determined that care staff empty R1’s catheter bag but all other catheter care is performed by a home health nurse. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to Executive Director Sonya Gonzales.