Complaint Investigation Report

Interview with W1 indicated that R1’s pressure injuries developed prior to admission to the facility. W1 believed that R1’s prior placement was responsible for R1’s pressure injuries. Incident report dated 3/23/2022 revealed that the facility reported R1 had two pressure injuries during admission. Interview with staff and residents indicates consistent statements of staff being attentive to the resident’s care needs. Staff knew to assist R1 with rotating and check on R1 frequently. R1 stated that he was receiving hospice care for coccyx pressure injury.

Staff failed to provide mobility equipment required to move bedridden resident in care

R1’s physician’s report dated 3/2/2022 indicated that R1 is non-ambulatory. R1’s functional capability assessment dated 3/7/2022 revealed that R1 requires assistance with transferring, but able to reposition from side to side. R1’s medical and hospice records did not indicate that R1 required mobility equipment for transfers. Interview with witness revealed that facility staff was assisting R1 in repositioning.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED .

Exit interview conducted with Chearamy Evangelista. A copy of this report provided.