Complaint Investigation Report

During this visit at approximately 11:45a.m., LPA Alvizar- Ettima and Staff #1 conducted a physical plan tour and did not observe any immediate health and safety issues. Between 12:10a.m. – 1:30p.m. LPA interviewed two (2) residents and attempt to interview two (2) however due to their health condition it was unsuccessful. One (1) resident was asleep, and one (1) resident was out of the facility with family. Facility staff indicated that Resident #1 (R1) no longer resides in the facility.

1.) Staff illegally evicted a resident in care.

It was alleged that R1 was illegally evicted because R1 has a stage 3 bedsore and after being discharged from hospital Administrator did not want to allow the R1 to return to the facility. All R1’s belongs from the room needed to be removed so Administrator could rent it to someone else. Administrator denied the allegation and stated that R1 was hospitalized due to medical concerns and was not denied re-entry to the facility. Administrator also stated that the Home Health RN and R1’s Nurse Practitioner had documented as a stage 3 wound. Staff interviews corroborated the Administrator’s statement. Staff reported that R1 was transported to the hospital for treatment and they were unaware of any eviction or refusal to readmit R1. Resident interviewed did not report concerns regarding resident evictions and were unaware of any incident of a resident being removed from the facility. No written eviction notice was issued to R1. A review of R1’s file and other facility records did not reveal any information to support the allegation.

Based on interviews and documents review there is insufficient information to support the allegations. Therefore, the allegation is UNSUBSTANTIATED at this time.

2.) Resident developed prohibited health condition while at the facility.

It was alleged that Resident #1 (R1) had a possible stage 3 bedsore and needed to be transported to hospital. However, R1 was admitted with a stage 2 pressure injury prior to admission to the facility.

The Administrator and staff verified that at the time of admission resident had existing Stage 2 pressure injury. Staff provided assistance and reminders regarding repositioning and skin care to R1. However, R1 frequently refused assistance with repositioning and preferred to remain in bed for extended periods. Staff routinely encouraged repositioning and documented resident’s refusals. Other residents interviewed did not report concerns regarding the care provided by facility staff. A review of Internal Notes reflected that staff provided education and reminders regarding repositioning and skin integrity.