complaint·May 14, 2025

Staff are not following physician's orders. On the allegation that staff are not following doctor’s orders, it is the concern of the Reporting Pary (RP) that the staff are not repositioning residents every two hours as indicated by the resident’s (R1) physician’s orders. To investigate the allegation, the LPA interviewed staff, residents, and the RP. Per the RP, the resident’s representative visited the resident during the weekend; after four (4) hours of being at the facility, R1’s representative noticed that the staff (S1) failed to turn the resident (R1) every two hours per doctor’s orders. When the resident’s representative asked the staff on site (S1) to reposition R1, the staff stated that they could not do it (physically). Furthermore, the R1’s representative stated that S1 was the only one at the facility on the day of the visit. The LPA interviewed the residents, and two (2) out of three (3) residents stated that they do not need assistance with repositioning, one resident stated that they get assistance from staff to turn and reposition throughout the day. Residents stated that typically, the facility’s representative is at the facility on weekends along with S1. The interview with the facility’s representative revealed that they were at the facility on the day of the visit, however they admitted that they went out to do some shopping for groceries and were not gone for more than an hour. The LPA was unable to interview S1, or R1. Record review revealed that R1 resided at the facility for two weeks, was admitted to the facility with hospice services; hospice record review indicated that R1 had to be reposition every two hours. Although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove the alleged violation did or did not occur; therefore, the allegation is deemed Unsubstantiated at this time. Residents are left in soiled diapers for an extended amount of time. On the allegation that residents are left in soiled diapers for an extended amount of time , it is the concern of the reporting party that residents get a diaper change only twice a day, once in the morning and once at night. To investigate the allegation the LPA interviewed staff and residents. The staff interviews revealed that staff check on residents every two hours day and night, but may need to change soiled diapers more often, depending on the need of the residents. Furthermore, staff stated that residents have a call button to call staff if they need to have a diaper change. The residents’ interviews revealed that they get a diaper change more often than two times a day, and/or as needed. Based on the information obtained through residents’ and staff interviews, it is apparent that residents get a diaper change throughout the day, and as needed or requested by residents. Therefore, the allegation is deemed Unsubstantiated at this time. No citations were issued at this time. Exit interview was conducted. A copy of the report was issued.