complaint·May 3, 2022

A resident was left in a soiled diaper for 2.5 days. During the investigation process the assistant administrator and seven staff persons were interviewed. In addition, an attempted interview was conducted with the resident (Resident 1); however, he was not able to respond to the asked questions due to his diagnosis. Documentation was received and reviewed to include the Physician’s Report, Admission Agreement, Appraisal and Needs Plan, Medication Administrative Record (MARs) and a doctor’s order from the Veteran’s Affairs (VA). In addition, three residents’ medications were reviewed. It was reported by all staff persons interviewed that they were not aware that the resident was left in a soiled diaper for 2.5 days. It was reported that the resident was difficult in that he was aggressive and combative, and at times would refuse to be changed by the staff persons. A doctor’s order was obtained from the Veteran’s Affairs (VA) Nurse Practitioner which stated, “The public guardian should be notified, and the patient should be sent to local emergency room for evaluation if he refuses perineal or incontinence care for any period of time exceeding 8 hours.” Staff reported that the resident had his medications changed and that he is now more amenable to having his briefs changed. It could not be proven that A resident was left in a soiled diaper for 2.5 days. 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 During the investigation process the assistant administrator and seven staff persons were interviewed. In addition, an attempted interview was conducted with the resident (Resident 1); however, he was not able to respond to the asked questions due to his diagnosis. Documentation was received and reviewed to include the Physician’s Report, Admission Agreement, Appraisal and Needs Plan, Medication Administrative Record (MARs) and a doctor’s order were reviewed. In addition, three residents’ medications were reviewed. It was reported by all staff persons that they were giving the resident his prescribed medication (Zinc Oxide) for a rash. It was reported that when the resident would refuse to be changed, the staff persons could not apply the cream. A review of cream medications for three of the residents were observed and their medications were in compliance. It could not be proven that Staff are not giving a resident prescribed medication for a rash. 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 .