Complaint Investigation Report

Allegation: Resident developed multiple pressure wounds while in care

During investigation, LPA reviewed resident’s (R1) admission agreement which showed R1 was first admitted at the facility on 09/24/23 with existing pressure injuries on his left buttock, R1’s hospital after visit summaries dated 10/2023 until 01/17/24 showed the home health care team and staff provided care and supervision in decreasing R1’s risk of recurrence of pressure injuries. Medical records also showed R1 was visited and treated by the home health care team several times (10/23/23 until 12/26/23) for pressure injuries and instructed staff on interventions to prevent pressure injuries using home care patient education guide. On 12/26/23, Home Health records indicate that R1 was discharged as No Further Home Health needed. Home Health records were reviewed and notes from the nurse did not indicate there were any concerns with facility staff providing the care needed for R1. Staff (ADM, S1) confirmed with LPA that they followed home health’s pressure injury instructions and ordered air mattress/cushions to aid in preventing pressure injuries. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the resident developed multiple pressure wounds while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.