complaint·May 12, 2022

Regarding Allegation #1 : Staff are not following Physicians orders. This complaint alleged that the administrator informed staff not to follow the physicians’ orders of washing the buttocks area with soap and water for R1. On 10/12/2021 LPA Calderon obtained and reviewed the physicians order dated 10/11/2021 for R1. The order states that the back bilateral buttocks and groin will be cleanse with soap and water. The order states the groin will be pat dried gently, and nystatin powder as well as triamcinolone cream 0.1% applied twice a day. The treated area would then be exposed to the open air. LPA Calderon conducted an interview with A1. A1 expressed that all staff follow the physician orders (dated 10/11/2021) for R1. LPA Calderon interviewed S1-S3 and 3 out of 3 staff expressed that they follow the physicians order and were trained to provide R1 with physician ordered care. LPA Calderon obtained and reviewed care plan records (dated 10/19/2021-01/22/2022) and found staff assisted R1 with incontinence services, repositioning, and applying ordered powder as well as medicated creams daily. On 05/12/2022 LPA Calderon reviewed Medication Administration Record for (May 2021) and found nystatin powder and triamcinolone 0.1% cream were administered per the physician’s order. 10/12/2021 LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments. LPA conducted an interview with W1 who visited R1 three times per week and expressed observing R1 being washed with soap and water when visiting. W1 was unable to confirm an absence of care was occurring when W1 was not present. Regarding Allegation #2 : Staff are not changing R1 diaper timely. This complaint alleged staff are not changing R1 diaper every 2 hours. On 10/12/2021 LPA Calderon obtained and reviewed the physicians order dated 10/11/2021 for R1. The order stated that R1 diaper should be changed every 2 hours or when needed. LPA Calderon interviewed A1. A1 state all staff follow the physician orders (dated 10/11/2021) for R1. LPA Calderon interviewed S1-S3 and 3 out of 3 staff expressed that S1-S3 were trained to change R1 diaper every 2 hours or when needed. 3 out of 3 staff expressed that S1-S3 were given incontinent training from A1 (dated 09/13/2021). 3 out of 3 staff expressed that staff keeps incontinent log records on changing resident every 2 hours (dated 10/19/2021 to 01/22/2022). LPA Calderon obtained and reviewed in service training for incontinent care and noted incontinent services provided every 2 hours to R1 (dated 10/19/2021 to 01/22/2022). LPA Calderon conducted an interview with W1 who visited R1 three times per week and states observing R1 incontinent services provided by staff every time W1 visited R1. W1 was unable to confirm an absence of care was occurring when W1 was not present. LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments. Regarding Allegation #3 : Staff are double diapering residents. This complaint alleged that staff are putting 2 diapers on R1. On 10/12/2021 LPA Calderon obtained and reviewed the physician order dated 09/30/2021 for R1. The order states that R1 has incontinent issues and needs to have incontinent services every 2 hours. LPA Calderon conducted an interview with A1. A1 expressed that S1-S3 were given incontinent care training on how to put a diaper on R1 (dated 09/13/2021). LPA Calderon interviewed S1-S3 and 3 out 3 staff expressed that A1 gave training to staff regarding diaper changing dated 09/13/2021. 3 out of 3 staff expressed that they would never put 2 diapers on R1 for any reason. LPA Calderon conducted an interview with W1 who visited R1 three times per week and expressed observing R1 diaper changed every 2 hours. W1 was unable to confirm an absence of care was occurring when W1 was not present. LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments. Regarding Allegation #4 : Resident developed pressure injuries while in care. This complaint alleged that R1 developed stage 2 pressure injuries to buttocks and back area while in care. On 09/18/2023 LPA Calderon obtained and reviewed the physician orders dated 09/30/2021. The order stated that staff reposition R1 every two hours. LPA Calderon conducted an interview with A1. A1 expressed that staff follow the physician order (dated 09/30/2021) for R1. LPA Calderon interviewed S1-S3 and 3 out of 3 staff expressed that all staff are given training in pressure injuries/bedsores from A1 (dated 09/06/2021). 3 out of 3 staff expressed that staff reposition R1 every 2 hours per the training given to them from A1 and the Cleveland Clinic training guide (dated 09/06/2021). LPA Calderon obtained and reviewed needs and service plan (dated 10/01/2021), reposition log notes (dated 10/19/2021 to 01/22/2022) and found staff assisted R1 reposition every 2 hours. LPA Calderon conducted an interview W1 who visited R1 three times per week and expressed that R1 did not have any sores on R1 buttocks area when R1 moved into the facility. W1 expressed that W1 does not believe that staff reposition R1 every 2 hours as directed from doctors’ orders but W1 has no proof. W1 expressed to have observed staff reposition R1 every 2 hours when visiting. W1 was unable to confirm an absence of care was occurring when W1 was not present. LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments. Regarding Allegation #5 : Resident is not being turned every 2 hours. This complaint alleged that R1 is not being repositioned every 2 hours per physician order. On 10/12/2021 LPA Calderon obtained and reviewed the physician order dated 09/30/2021. The order stated that staff reposition R1 every two hours. LPA conducted an interview with A1. A1 expressed that all staff follow the physician orders (date 09/30/2021) for R1. LPA Calderon interviewed S1-S3 and 3 out of 3 staff expressed that they follow the physician order and were trained to provide R1 with physician ordered care. 3 out of 3 staff state that they reposition R1 every two hours. On 09/18/2023 LPA Calderon obtained and reviewed reposition and incontinent care log notes (dated 10/19/2021 to 01/22/2022) and found staff assisted R1 with repositioning services. LPA Calderon conducted an interview with W1 who visited R1 three times per week and expressed observing R1 being repositioned every 2 hours by staff. W1 was unable to confirm an absence of care was occurring when W1 was not present. LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments. Regarding Allegation #6 : Resident is not being cleaned properly. This complaint alleged that staff are not giving R1 a bath while in care. On 10/12/2021 LPA Calderon obtained and reviewed the physicians order dated 10/11/2021 for R1. The order said that the back bilateral buttocks and groin will be cleanse with soap and water. The order states the groin will be pat dried gently, and nystatin powder as well as triamcinolone cream 0.1% applied twice a day. The treated area would then be exposed to the open air. LPA Calderon conducted an interview with A1. A1 expressed that all staff follow the physician orders (dated 10/11/2021) for R1. LPA Calderon conducted an interview with A1. A1 expressed that all staff follow the physician orders (dated 10/11/2021) for R1. LPA Calderon interviewed S1-S3 and 3 out of 3 staff expressed that they follow the physician order and were trained to provide R1 with physician ordered care. LPA Calderon obtained and reviewed bath care log records (dated 10/19/2021-01/22/2022) and found staff assisted R1 with sponge bath services. LPA conducted an interview with W1 who visited R1 three times per week and expressed observing R1 being washed with soap and water when visiting. W1 was unable to state that staff did not provide a sponge bath was occurring when W1 was not present. W1 was unable to confirm an absence of care was occurring when W1 was not present. LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of Staff are not following Physician's orders, Staff are not changing resident timelyStaff are double diapering residents, Resident developed pressure injuries while in care, Resident is not being turned every 2 hours, Resident is not being cleaned properly is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to the Administrator A1