St. Pauls Health Care Center

During an interview on 9/3/25 at 11:05 A.M., LN 1 stated on the morning of 8/3/25 CNA 1 notified him she was concerned about Resident 1's brief placement. LN 1 stated he observed CNA 1 remove Resident 1's outer brief and saw a folded brief with a hole cut through the middle and Resident 1's meatus sticking through the hole. LN 1 stated Resident 1's penis appeared swollen and discolored and the opening was so tight it was acting like a rubber band. Resident 1 was guarded during the physical assessment. LN 1 stated the practice of putting a resident in two briefs was not acceptable and was considered a form of neglect. LN 1 stated there was visible skin breakdown where the brief was restricting the tip of the penis. LN 1 stated the person who placed Resident 1 in the briefs was identified as the overnight (NOC) CNA from registry (a staffing agency).

During an interview on 9/4/25 at 4:20 P.M., the nurse administrator (NA) stated she had completed the internal investigation of the alleged abuse involving Resident 1 and found that NOC CNA was responsible for double briefing the resident. NA stated double briefing should never be done because it increases the risk of skin breakdown. NA stated it was the facility's policy to never double brief residents and all CNAs were expected to be competent and implement best practices.

The NA stated registry staff should complete their competencies before coming to work on the floor. NA stated she was unable to find any type of documentation that verified NOC CNA's competencies were completed before working at the facility. NA acknowledged Resident 1 experienced psychosocial harm from embarrassment and reported pain as well as potential for injury because NOC CNA applied two briefs in an unsafe manner. NA stated the facility was unable to guarantee the safety of their residents if standards of care were not being met. A review of the facility document titled, Allegation of Abuse - 5 day summary report, dated 8/7/25, indicated .Summary of Incident: On August 3, 2025, at approximately 11:45 AM, Charge RN [CN] was notified by CNA [1] that Resident [1] was found to be double briefed during routine morning care.

One brief was placed correctly, while the second had a hole cut in the center through which the penis was pulled, causing constriction.

This resulted in swelling and discoloration of the meatus, and the resident reported discomfort.

Follow up investigation.

August 5, 2025. CNA [NOC CNA] (Night Shift, Registry) was interviewed. He admitted to applying two briefs in the described manner and stated that this was part of his routine practice with residents he considered heavy wetters. He acknowledged having used this technique in other faculties.

The facility's investigation substantiated that improper continence care had occurred, constituting neglect.

The CNA's actions resulted in physical harm to the resident and were inconsistent with regulatory standards, resident rights, and facility protocols.the deviation from accepted practices posed a risk to resident safety and dignity.

Conclusion: After a thorough investigation was conducted, it was determined to be a substantiated case of neglect based on deviation from standard care practice. A review of the facility policy titled, Abuse and Neglect - Clinical Protocol, approved March 2025, indicated, Policy Statement. 2.

Neglect, as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 5.

Along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect; for example. failure to provide incontinence care Cross Reference: see F-F726

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

St.

Pauls Health Care Center

235 Nutmeg Street San Diego, CA 92103

SUMMARY STATEMENT OF DEFICIENCIES