complaint·April 22, 2025

Complaint states the resident presented at the emergency room on 9/3/22 with Foley Catheter pulled out, but a portion still inserted into R1 and that the foley bag was not appropriately placed, was unclean and open to infection. In addition, the resident was covered in feces. Prior to the visit LPA Rankin reviewed staff interviews provided by prior LPA Torres, as well as contacted additional staff interviews via phone calls. Interviews of facility staff done by both LPA’s, as well as records obtained showed R1 had been re-admitted to the facility approximately late afternoon of 9/2/22 after being discharged from a Skilled Nursing Facility (SNF), and all staff interviewed stated, that on the morning of 9/3/22 R1 had either driven over or cut their catheter that was connected to the foley bag causing it to be disconnected. Urine was dripping from the tube which was being dragged around the floor behind R1’s scooter. Staff interviewed and records reviewed stated that R1 was not acting in their usual character, R1 was in the lobby without their shirt, and was slurring words, R1 was confused, and when staff went to R1’s room they smelled urine and noticed feces. Staff called 911 to have R1 transferred due to the foley cather bag needing to be repaired, and the residents change in behavior. Records review showed that R1 had a UTI when admitted to the hospital. The time frame for R1’s stay at the facility was less than 24 hours. R1 was discharged on 9/2/22 from the SNF and the resident was sent out the early afternoon of 9/3/22 from the facility. Based on interviews, and records reviewed. The allegations may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Copy of report printed and given to Licensee.