complaint·April 14, 2022

The administrator also stated staff changed R1’s brief on the bed before R1 went to the hospital and put two briefs on R1 and put a chuck pad under R1 for extra protection. The administrator and staff confirmed they do not normally put two briefs on a resident, but have when the resident is being sent to the hospital since they are not sure how long the resident will be there. Administrator stated they don't want residents to be uncomfortable so do all they can to unsure residents are changed before leaving the facility. Administrator stated it took 20 minutes for the ambulance to leave, when the ambulance got to Twin Cities Hospital there were no beds and R1 was left in the Ambulance for 30-45 minutes before one was available. The hospital nurse only noted the briefs were soiled, but did not note double diapering. Staff interviews and documentation confirmed they check residents requiring incontinence care every 2 hours, as well as before and after each meal. Residents interviewed stated their needs were met and they did not have any concerns. An interview with R1’s POA revealed the POA was R1’s primary caregiver for years prior to R1 living in this facility. The POA stated R1 does not like anyone to change R1 and R1 would prefer to stay in a soiled garment rather than tell a caregiver they are soiled, due to the emotional aversion of someone changing R1. The POA stated they have no issues or concerns with the care the facility provides and feels the staff do a “great job” taking care of R1. The POA stated they saw R1 through a window visit at the facility on 1/13/2021 and on 1/14/2021. The POA stated R1 was changed during both visits and that the staff did a good job changing R1 in light of the higher changing needs of R1. Based on the information obtained, the allegation is deemed unsubstantiated at this time. Exit interview, report emailed. A Technical Assistance Advisory Note was issued to advise administrator not to put two briefs onto residents.