complaint·January 31, 2024

If they were wet, they would be changed. According to a former staff member, they would be assigned approximately 20 to 30 residents, but they checked if changing was needed. They mentioned that there may have been times where other staff may not have changed all their residents, but they never witnessed, nor did they miss in changing their assigned residents. Staff and former staff did say that there were residents who would either refuse or give staff difficulties changing them. When this occurred, staff would switch resident checks to observe if another staff member would be able to assist with those who refused or had difficulties with. No staff reported issues with other shifts not keeping up with their checks. Former and current staff reported working well with their co-workers. In review of the facility documents, it was noted that the resident had a loss of cognitive functioning and needed one-person standby assistance for toileting needs. Documents show that the facility needed to assist the resident in the bathroom every two hours for toileting assistance. According to the facility service plan, it annotated that incontinence care or toileting service while resident is awake; if the resident refused, they would need to inform nurse on duty and or the RSD; also, if resident refused care to a care staff, they would try change of staff face technique. It was noted that the resident was able to shower self and noted that at times R1 refused to be showered by their third-party agency. The facility did have incontinence checks logs for R1 the months of August 2020 and September 2020 only. According to records, staff would change the R1 between 6:30 AM – 7:30 AM; with mainly staying within the range assisting the resident in the morning with incontinence care at about 7:00 AM. The facility staff incontinence checks ranged daily between 28 minutes to about 3 hours but staying within the range of checking R1 every 2 hours between the hours of around 7 AM until about 10 PM. Incontinence checks indicated if the resident needed to be changed or was dried at the time of the check. Based on the information obtained during interviews and records reviewed, there is insufficient evidence to support the allegation. It was specifically alleged that due to staff not changing R1 throughout the night, R1’s entire room was malodorous when they opened their door. Staff and former staff interviewed did not raise concerns regarding residents not being changed during their assigned shifts. If staff did not have issues with residents being changed, there would be no indication that there were residents who had a malodorous room due to staff not checking residents’ incontinence care. Based on the evidence obtained during the investigation, there is insufficient evidence to support the allegation. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside sources interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director McCoy, and Resident Service Director Reyes . A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to ED McCoy at the conclusion of the visit. The signature below confirms the documents were received.