complaint·September 13, 2022

The investigation revealed the following: Allegation - Resident sustained an injury while in care. It was alleged that Resident #1 (R-1) sustained a severe UTI as a result of being left in soiled diapers for extended periods of time. The Investigations Branch (IB) Investigator Brian Slatic conducted the investigation on this allegation. All the staff interviewed denied R-1 was left in a soiled diaper for extended periods of time. The facility policy requires the residents to be checked at least every 2 hours. In addition, Investigator Slatic obtained and reviewed hospital records for this investigation. Although R-1 did sustain an UTI, it cannot be conclusively shown that it was a result of lack of staff supervision or neglect. Based on interviews and records reviewed by the Investigator, there is not supportive evidence to concur with this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with the Administrator. A copy of this report along with the appeal rights were provided. One of the six staff admitted that Resident #1 (R-1) had requested to be moved to the toilet on 6/4/21 but did not take resident to the toilet. Staff indicated a fresh brief was placed on R-1 and checked on resident every 2 hours instead. R-1 had requested to use the toilet all night and Staff did not believe resident needed to have a bowel movement. It was also noted that R-1 was never transferred out of the bed to the toilet during the NOC shift and that resident required two-person transfer. The other 5 staff who the investigator interviewed denied neglecting any resident's request to be transferred to the restroom. They would honor any residents' requests and take them to use the toilet. Based on interviews conducted, 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 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.