Complaint Investigation Report

Staff neglect resulted in resident sustaining multiple pressure injuries. - UNSUBSTANTIATED

Based on R1’s care plan and care needs, R1 was independent in their care. R1 needed standby assistance in the shower. R1 was able to conduct all other aspects of their care on their own. On 8/20/2025, staff were cleaning R1 after R1 had a toileting accident and noted R1 had black tar like stool and blood on their rectum, it was also noted R1 had a black toe on their right foot. Staff were not aware of the black toe prior to this. Per R1’s care plan staff had no expectation to perform body checks on R1. Staff would not have seen the toe as R1 showers and dresses themselves. R1 is also able to communicate their needs and voice if R1 is in pain. R1 voiced no concerns nor complaints of pain.

On 8/20/2025, R1 was admitted to Renown Regional Hospital on 8/20/2025 due to “Acute osteomyelitis of toe of right foot.” R1 was also admitted due for gastrointestinal bleeding. R1 received wound care treatment due to “noted bone exposure.” On 8/22/2025, “Patient was taken to the OR by orthopedics on 8/22, underwent disarticulation of a necrotic second toe.”

It was also discovered R1 had pressure wounds to their “Pretibial Proximal Left” (Amputated leg), and “Right Lateral Hallux” (amputated toe). R1 also had “Buttocks incontinence dermatitis” (showed a red and inflamed area around their buttocks which turned white). R1 was discharged on 8/26/2025 to Lassen Nursing and rehab.

Based on R1’s care plan and their independence in care, the staff had no reasonable expectation to perform body checks on R1. R1 voiced no concerns nor voiced they were in pain. The preponderance of the evidence has not been met; therefore, the allegation is unsubstantiated.