Complaint Investigation Report

The investigation revealed the following: regarding the allegation “ Staff did not prevent client from developing multiple stage 2 pressure injuries while in care .” It is alleged staff did not prevent a client from developing stage 2 pressure injuries. During the investigation, LPA Ramirez requested and received C1’s Appraisal/Needs and Services Plan dated 3/12/2024, which indicated that C1 is ambulatory, can independently maneuver through familiar spaces, and C1 often walks on their toes (while their toes are turned in) while barefoot, and enjoys running and/or galloping from space to space. Review of Unusual Incident/Injury Report dated 8/19/2024, revealed that on 8/16/2024, C1’s family observed C1 was limping and took C1 urgent care. Review of C1’s Urgent Care summary dated 8/16/2024, revealed that C1 was observed to have second stage pressure ulcer on right and left distal lower extremity. Review of C1s Body Check form dated 07/01/2024 through 07/31/2024 did not indicate that C1 had a pressure injury during this period. Review of Body Check form dated 08/01/2024, revealed that staff observed and documented an injury to the bottom of C1s heel and foot. Three (3) out of the three (3) staff interviewed denied the allegation. Interview with staff#2 (S2) revealed C1 has a habit of sitting on their feet, however, staff redirect C1 to not sit on their feet. Interview with staff#3 (S3) revealed C1 tends to sit on C1s feet, however, C1 is redirected to sit down on C1s bottom and/or staff will ask C1 if C1 would prefer to go out for walk instead of sitting on C1’s feet. Review of appointment record dated 9/14/2024, revealed C1’s second stage pressure ulcers have healed and C1 may return for follow-up care every 2 months if symptoms re-develop. Due to C1’s limited verbal responses and cognitive abilities, C1 was unable to provide a meaningful interview. The investigation revealed that C1 did develop a stage 2 pressure injury to C1s foot/heel, however, there was no evidence to support that staff neglected C1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED .

No deficiencies were cited during this complaint investigation. Exit interview conducted. A copy of this report was provided.