complaint·April 12, 2022

A resident is being transferred from bed to toilet in an unsafe manner . During the investigation process the assistant administrator and five staff persons were interviewed. In addition, the resident (Resident 1) was interviewed. Documentation was received and reviewed to include the Physician’s Report, Admission Agreement, How to use a Hoyer Lift requirement and a Hoyer Lift Inservice Signoff document. During the initial visit at the facility, Misty Valencia and Dawn Keene, two Licensing Program Analysts (LPAs) went to the resident’s room to view the concern of the Hoyer Lift being moved from the resident’s bed to the bathroom. It was reported and observed by the LPAs that the threshold was at a “normal height.” All staff persons reported that there was not a problem with using the Hoyer Lift with the resident and that the Hoyer Lift was always used with two staff persons assisting. The resident was interviewed, and she reported that she felt “safe” when the staff persons were using the Hoyer Lift. There was no report that an incident occurred with a transfer in an unsafe manner. Records were received and reviewed indicating that staff have been trained in using a Hoyer Lift. It could not be proven that A resident is being transferred from bed to toilet in an unsafe manner. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated . continued Resident left in bed in her own urine . During the investigation process the assistant administrator and five staff persons were interviewed. The resident (Resident 1) was not interviewed, as she is no longer residing at the facility. Documentation was received and reviewed to include the Physician’s Report and Admission Agreement. It was reported that the resident needed assistance in incontinence issues. All staff persons advised that they were not aware that the resident was left in bed in her own urine, as the resident was on an incontinence schedule that they followed. It could not be proven that A resident was left in her bed in her own urine. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated . Although it was not indicated that the resident was left in bed in her own urine, the staff are required to follow a bowel and bladder program developed by a skilled professional. The staff have indicated that they followed a schedule; however, the staff have not been trained by a skilled professional, as required. Based on this information, the facility shall be cited on a separate report, LIC 809, on this date. (See LIC 809).