Complaint·June 2, 2024

INVESTIGATION REVEALED THE FOLLOWING: Allegation #4: Staff are not meeting resident's hygiene needs. Allegation #5: Staff are leaving resident in urine-soaked items for an extended period of time resulting in wounds and skin tears. The details of this complaint alleged staff are not meeting resident #1 (R1)’s hygiene needs which includes leaving (R1) in urine-soaked diapers for a long period that resulted in wounds and skin tears. The complainant reported (R1) appeared to be unclean, had nails with fecal items, and had hair matted, dirty, and unkempt. The complainant claimed (R1) has not been changed for an extended period and had an extensive amount of urine, as an indication of (R1) not being changed regularly. The complainant stated (R1) that wounds and skin tears may contribute to poor and neglectful handling. The complainant did not have further details information on these allegations as to the dates, time, and staff involved. The investigation revealed resident #1 (R1)’s Identification and Emergency Information LIC601 (dated: 08/23/22) and Admission Agreements for Residential Care Facilities for the Elderly (dated: 08/23/22), (R1) was admitted at Santa Fe Home II on 08/23/22. As outlined in (R1)'s Faith & Hospice & Palliative Care Inc Patient Profile (dated: 08/24/22) care services began on 08/24/22. (R1) voluntarily terminated residency at this facility on 09/20/23. On 09/28/24, between 9:30 am – 1:07 pm, the Department interview (3) out (3) administrator (A1) and staff #1-#3 (S1-S3) denied these allegations. (A1) and (S1-S3) all confirmed that (R1) was under hospice care a home aide would come to assist with hygiene and grooming care. Hospice aides and nurses monitor vital signs and personal hygiene three times a week. The facility staff would step in when (R1) refused hygiene and grooming services from a hospice home aide. (A1) claimed that (R1) was entitled to (R1’s) personal rights. There were often when (R1) declined to receive assistance with hygiene and grooming care from staff. The staff is respectful of (R1’s) rights and has the right to refuse such basic services. (A1) and (S1-S3) claimed that (R1) was repositioned, monitored, or changed at least every two hours or as needed. (S1-S3) denied leaving (R1) in urine-soaked diapers for an extended period. (S1-S3) communicated even at night shift hours of 11 pm – 6 am there is a staff on shift to attend to (R1)’s incontinence needs. (Evaluation Report continues LIC 9099-C) (A1) stated that (R1) was previously cared for at a skilled nursing facility and when admitted at Santa Fe Home Care II, (R1) already had minor skin tear. (A1) indicated that under hospice plan of care, a wound care plan was included. The wound care plan included to reposition, keep (R1) clean, dry and apply barrier cream every two hours. (A1) communicated that (R1) was under professional supervision and care with nurses and doctors while (R1) was at Santa Fe Home II. (R1)’s family members were at the facility during hospice visits with nurses discussing (R1’s) condition. (A1) stated when it came to (R1)’s medical needs it was always taken care of by hospice medical professionals. (A1) claimed the facility staff were only responsible for (R1)’s non-medical care since the facility is a non-medical care facility. On 09/28/24, between 10:45 am – 11:37 am, the Department interviewed (4) out (4) residents #2-#4 (R2-R4) all claimed that staff are responsive and are observant to resident's changes in condition and needs. (R2-R4) reported that when they require assistance, the staff is available even during the night shift. (R2) who is independent and shared a room with (R1) has observed that (R1)’s incontinence, hygiene, and grooming needs are being attended to timely by hospice and staff at the facility. On 09/28/24, between 9:47 am – 04:07 pm, the Department interviewed (3) out (3) family representatives witness #2-#4 (W2-W4) claimed the facility appeared to be adequately staffed. (W2-W4) who are very much involved with resident care at this facility with frequent visits and have not witnessed any activity of neglect or lack of care toward residents. (W2-W4) claimed (R2-R4) have not endured wounds while in care. Several telephone calls were made to family representatives for (R1), witnesses #1 and #5 (W1 and W5), but no comments were obtained. On 09/14/24, between 10:37 am – 10:57 am, the Department attempted to interview resident #1 (R1). Due to (R1)’s health condition, (R1)'s ability to make full statements or carry on a conversation was limited. (R1)’s appearance was presentable. (R1) appeared to be in clean clothing and groomed. Between 12:00 pm – 01:00 pm, the Department observed the hospice aide as well as staff #2 (S2) assisting with (R1’s) incontinence needs, grooming, and changing sheets for maintaining good hygiene. Faith & Hope Hospice & Palliative Care did not return several telephone calls and could not provide additional records. (Evaluation Report continues LIC 9099-C) According to Faith & Hope Hospice & Palliative Care records Flow Sheet (dated: 07/11/23 through 09/19/23) and Visitation Logs (dated: 05/11/23 through 09/19/23) verified visits occurred weekly. A Patient Medical Profile (dated: 08/24/22) confirmed that a care plan for (R1) illustrates the needs and services supplied by hospice. Physicians Report LIC 624A (dated: 08/05/22) and Appraisal/needs and Services Plan LIC 625 (dated: 08/05/22) revealed (R1) is not able to self-care and requires assistance with bathing, grooming, and toileting. In addition, the complainant expressed concerns that individuals who are acquaintances of facility staff wandered freely through the facility without supervision. Interviews with the facility staff, residents, and family representatives as well as a review of the Visitation Log were unable to support this claim. Based on the evidence gathered, interviews conducted, and analysis of records, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations of NEGLECT/LACK OF SUPERVISION: “Staff are not meeting resident's hygiene needs” and “Staff are leaving resident in urine-soaked items for an extended period of time resulting in wounds and skin tears” are determined to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to the staff #1 (Lucy Dezell).