complaint·October 27, 2023

However, interviews with R4 revealed that staffs are not changing their diaper at nighttime and R4 reported to LPA Brown "If I'm wet or I dirty my diaper at night, I have to wait until the morning to be changed and the most recent date this happened was three (3) weeks ago." Also, interviews with R2 and R3 indicated that staff are changing their diapers during the day and at bedtime and R2 and R3 did not report that staff at the facility are checking or changing their diaper at nighttime. Interviews with Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3) indicated that no resident was left with a soiled diaper for a long period of time causing resident to develop wounds. LPA Brown asked if the facility has a record of their residents’ incontinent care and S1, S2 and S3 reported to LPA Brown that no such records exist. LPA Brown requested a copy of Care Notes/Progress Notes for their residents and S1, S2 and S3 revealed they do not have Care Notes/Progress Notes for their residents. Moreover, LPA Brown observed staff inconsistent report as to how often staff at the facility checked on their residents and change their diaper. Also, during the visit on 10/23/2023, LPA Brown requested the facility's Personnel Summary (LIC500) from S2 and LPA Brown observed that no staff are scheduled to work on a night (NOC) shift and immediately address the issue with S2. S2 updated the facility's LIC500 showing S2 as staff coverage on NOC shift. Furthermore, staff interviews with S1, S2 and S3 indicated something described as R1's scratching behavior that resulted to a wound on R1's buttocks was observed on 06/2023. S1, S2 and S3 confirmed with LPA Brown that they did not seek medical assistance regarding this observation. S1 and S2 reported to LPA Brown that they reported the incident to R1's responsible party but failed to report to R1's primary physician. Interview with S3 revealed that they treated the wound with hydrocortisone and moisturizer provided by R1's responsible party. Investigation revealed that on 09/28/2023, R1 was admitted for Hospice Care and upon admission, medical records show that R1 was diagnosed with Stage 2 Pressure Ulcer of left buttocks. Based on LPA Brown's investigation, it is concluded that there is sufficient evidence to substantiate allegation of Staff left resident in a soiled diaper for a long period of time causing resident to develop wounds. It was evident that R1 required staff assistance with activities of daily living, including incontinent care. However, it was found that facility staff failed to provide the services needed by R1 to meet R1 needs. As a result, R1 sustained Stage 2 Pressure Ulcer of left buttocks while in care. ***Continuation in LIC9099C *** A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report (LIC9099), LIC9099D and Appeal Rights were discussed, and a copy was provided to Licensee/Administrator Evafe Green - Sosnovsky and Administrator Russel Bernardo at the conclusion of the visit.