complaint·May 26, 2023

Page 2 When R1’s door was unlocked by staff, it was 11:00 a.m. and there was a concern that staff had not checked on R1, as R1 was soiled. In addition, the witness could not find a staff person to assist with changing R1. Interviews and observations confirmed that whereas the resident doors locked from the exterior, the lock is disengaged once residents turn the handle from the inside and residents can successfully leave their room. Per records review and interview, although R1 was in their room until 11:00 a.m. on 05/08/2023, it was confirmed that staff continued to conduct status checks on R1. R1 was checked on and assisted with the self-administration of medication at 10:00 a.m. on 05/08/2023. Interviews and record stated that oftentimes, R1 has trouble sleeping and would often be awake through the night. The LPA reviewed charting notes for 05/08/2023, and it was documented that R1 was awake throughout the night 05/08/2023 until 4:00 a.m. Staff entered the note on 05/08/2023 at 6:16 a.m. and indicated that R1 was asleep ‘at that time’. Notably, staff indicated that is hard to get R1 up in the morning because of R1’s struggles with sleeping, hence R1 will frequently sleep until 11:00 a.m. A review of charting notes and interviews supported claims that due to an infrequent sleeping schedule at night and medication effects, R1 will sleep in their wheelchair mid-morning or will appear drowsy. However, staff and records supported claims that although R1 sleeps late, staff will assist R1 with the self-administration of medication in the morning, and staff will continue to conduct status checks on R1 in the morning to see if R1 wanted to wake up. Staff claimed that in the mornings, R1 will refuse to get up and will ask staff to return at a later time. Staff indicated they will ask R1 if they were ready to get up or to have breakfast, but also recognized they are unable to force R1 to get up because it would have been a violation of their personal rights. Per the incident on 05/08/2023, a witness claimed that upon seeing R1 at approximately 11:00 a.m., R1 was soiled. At that time, the witness claimed they were unable to locate a staff member to refresh R1 and/or to change R1 into clean clothing prior to providing services to R1. Due to time constraints, the witness provided physical therapy services to R1 without obtaining care assistance from staff. The LPA reviewed the staffing schedule for 05/08/2023 and noted that there were at least four (4) care staff on shift, not including managerial staff. Yet, staff may have been occupied with providing care to other residents. There was no indication that the witness pulled the resident’s pull cord to obtain staff assistance. The witness claimed that they were unable to find a staff person in the immediate vicinity of R1's room. Based on the information obtained from interviews and record review, there is insufficient evidence to support the claim that staff neglected R1. This allegation is deemed unsubstantiated at this time. Page 3 Regarding the allegation: Staff left resident unattended in soaked dirty clothes. It was alleged that on 5/08/2023 at approximately 11:00 a.m., R1 was found to be in their room soiled.Staff supported claims that regular status checks were conducted on R1 the morning of 05/08/2023. Interviews with the Executive Director and staff stated that R1, at times, will become physically aggressive when refusing care. As a result, staff will attempt to return within 5-10 minutes to try and meet the care need. Staff claimed that they are eventually successful with meeting R1’s care needs when they give R1 space, as R1 can quickly become agitated. Staff claimed that oftentimes, they will bring an additional staff member to assist with R1’s care. In fact, records indicated that on 05/08/2023, R1 had been assisted with the self-administration of medication at approximately 10:00 a.m. The staff that observed R1 at 10:00 a.m. claimed to have only assisted R1 with medication and did not observe any immediate care concerns. Per the staff, residents are regularly checked every two (2) hours. Interviews and a review of R1’s medications confirmed that R1 was prescribed Furosemide (which according to Mayo Clinic, is a diuretic to treat fluid retention) and Tamsulosin (which according to Mayo Clinic, helps with the increase the flow of urine). Records indicated that R1 receives both Furosemide and Tamsulosin in the morning and the evening. R1 had received these medications prior to 11:00 a.m. Staff claim that due to the medication, R1 often has incontinent accidents. Staff confirmed they check on R1 regularly throughout the shift and indicated that even after staff have assisted R1 with using the restroom or changing their brief, R1 will continue to urinate. Staff made the claim that R1 is 'always soaked in urine' and have to frequently change R1's clothing and bedding. A care conference was held regarding R1’s care on 5/16/2023, and a medication adjustment was made to the frequency in which R1 is assisted with Furosemide. Based on the information obtained in interviews and records, there is insufficient evidence to support the claim that staff intentionally left R1 unattended in soiled dirty clothing. Although R1 was in their room, R1 was checked to ensure if R1 required assistance. Staff indicated that due to R1’s medications, R1 is regularly soiled. As such, even though staff regularly check on R1, R1 is known to have incontinence accidents even within a small window of being checked by a staff member. Per records, staff had checked on R1 and assisted R1 with the self-administration of medications at 10:00 a.m. on 05/08/2023, which may have caused R1 to have an incontinence accident. There was no indication that R1 was observed to be soiled at 10:00 a.m. on 05/08/2023. This allegation is deemed unsubstantiated at this time. Page 4 Regarding the allegation: Staff failed to meet resident's needs It is alleged that due to staff negligence, R1 was left unattended and soaked in urine. In addition, there was a concern that R1 was observed in the same ‘dirty clothes’ from the day before. Staff interviews indicated that oftentimes, R1 refuses to be changed into new clothing. Staff who work the evening shift indicated that they make regular attempts to try and convince R1 to change into their pajamas before going to bed; however, some staff indicated that R1 has gone to bed without changing into their pajamas. Yet, staff said they always ensure that R1 is assisted to the restroom or that their brief is changed before R1 is asleep. Information from staff interviews supported claims that staff were 'sometimes' successful in getting R1 to change their clothing, but claimed it takes a lot of convincing. Staff said that if they are unable to meet a care need prior to the end of their shift, they will inform the care staff for the next shift that R1 needs additional assistance or that they were unable to meet a need. Staff also indicated that, if need be, they will obtain the assistance of another staff person to assist with providing care to R1. Interviews and a review of R1’s medications confirmed that R1 was prescribed Furosemide (which according to Mayo Clinic, is a diuretic to treat fluid retention) and Tamsulosin (which according to Mayo Clinic, helps with the increase the flow of urine). Medication records indicated that R1 receives both Furosemide and Tamsulosin twice a day. Staff claim that due to the medication, R1 often has incontinent accidents. Staff reported that because of R1’s incontinence, they are regularly changing R1’s clothing and staff admitted that R1 receives up to seven (7) showers a week due to their incontinence. Staff confirmed they check on R1 regularly throughout the shift and indicated that even after staff have assisted R1 with using the restroom or changing their brief, R1 will urinate. A care conference regarding R1’s care was held on 5/16/2023, and a medication adjustment was made to the frequency in which R1 is assisted with Furosemide. Based on interviews and record review, there is insufficient evidence to support the claim that staff failed to meet R1’s needs. It was indicated that staff checked on R1 at 10:00 a.m. on 05/08/2023 and staff did not need to address any immediate care needs. Individuals who regularly visit R1 to provide care denied claims of ever observing staff neglect and indicated that R1 is always clean and well kempt. This allegation is deemed unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.