complaint·April 29, 2021

Allegation: "Resident's diapering needs are not being met. " Based on information obtained from document review and interviews conducted the findings reveal that night shift staff are expected to change resident's diapers at 7:00 pm, 10:00 pm, 2:00 am, 5:00 am, and if needed in between hours. The day shift staff change the resident's diapers at 7:00 am, 12:00 pm, 5:00 pm, and in between hours as needed. Resident's bedtime is at 7:00 pm. Staff (S1- S4) denied not changing the resident diapers after the 7:00 pm diaper change until the next day at 6:00 am. Staff (S2) was interviewed and initially stated that it lives at the facility, but later denied sleeping during night shift hours and failing to meet the resident's nighttime diapering needs. A total of four (4) staff were interviewed, all denied knowledge of night shift staff sleeping during shift hours. The facility plan of operation states they have awake staff 24 hours a day. Observations made on 4/14/21 & today resulted in deficiencies under a case management visit. Residents (R1-R3) did not report any issues with incontinence care, or knowledge that other resident's diapering needs are not being met. Residents (R4-R6) were not interviewed due to cognitive/communication disability. A total of seven (7) family members and/or authorized representatives of current and former residents were interviewed. None reported knowledge or observations of incontinence care issues or diaper change problems. The majority of the resident's receive day time family visits. Therefore, family members could not confirm diaper change negligence during night time hours. Administrator stated that there is one resident whose Foley catheter is changed every 2 hours. Staff gently wake up resident's in need of night time incontinence care so they could be comfortable throughout the night. Staff denied leaving residents soiled or wet during nighttime hours. Hospice residents are also assisted with diapering needs by hospice providers. Based on interviews conducted and information gathered there is insufficient evidence to prove the allegation . The findings indicate that 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. A telephonic exit interview was conducted with Administrator Theresa Kholoma. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.