complaint·April 26, 2023

That staff was going to get them up and shower them. Staff observed client unresponsive so called the administrator who said to call 911. LPA asked how often they check on C1 overnight. S1 stated they check on them every 2 hours. LPA asked how they check and staff said “I go in and check” LPA asked to show LPA and S1 walked into the room and turned their head in the direction of the bed. LPA asked how they know if they are wet or not. Staff stated, “oh yeah I go like this” LPA observed S1 to pat the bed. LPA asked if they pat their bottom or top to see if the diaper is full? S1 said yes. LPA asked what diapers they use for overnight. S1 said the overnight diapers and Depends pull ups over them. LPA and QAS interviewed a second Staff (S2) who stated they went to check on Client 1 and they didn’t wake up, they looked white. The other staff called the Administrator who said to call 911 and so they called 911 and AMR came in 10 minutes. LPA asked what the resident was wearing, staff responded “Pjs, sweatshirt and socks, 2 briefs one white one grey, white on the inside grey on the outside” LPA asked if they checked their diaper. S2 responded “No I didn’t check I smell poo but I can’t not change (C1) because we are calling 911.” All staff stated Client 1 didn’t seem different the night before. They stated C1 ate fine and acted the same and there was no indication of an Urinary Tract Infection (UTI). Administrator takes all staff and client temperatures every morning. LPA reviewed the resident temperature logs for the week and observed C1’s temperature to be between 97.3- 97.6 degrees Fahrenheit. LPA interviewed C1’s responsible party (RP), who stated they felt the facility took really good care of Client 1. The RP also stated the facility caught a UTI that C1 had last year, based on the smell and color of C1’s urine. The RP was impressed because C1 was not verbal and couldn’t communicate. The RP was not concerned that the facility missed this UTI and stated C1 got UTI’s often and UTI’s were common in C1’s medical history and family medical history. Based on the investigation, the facility staff stated they “checked” on the incontinent clients overnight just by looking at them across the room, then added that they pat the diapers on the clients when the LPA questioned their response. Staff admitted to regularly double-diapering clients, and admitted to not promptly changing a resident who had a diaper soiled with feces. Based on the information obtained, the allegation Facility did not meet resident's incontinence needs is Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9090-D). An exit interview was conducted, a copy of the report and appeal rights were issued.