Complaint Investigation Report

The investigation revealed the following:

In regards to the allegation: “Resident developed injuries (wounds) while in care.” It is alleged that a resident was sent to the hospital after developing wounds on his buttocks. No other details provided. Staff interviewed stated that they do rounds regularly to check on residents. Staff indicated that residents' diapers are changed every 2 hours, or as needed to keep them clean and dry. Staff also stated that they reposition resident to prevent rashes, sores or wounds. Staff also stated that when caregivers notice rashes or wounds, they report it immediately to the Med Tech for assessment and doctors are notified for treatment and to authorize care from a Home Health nurse or wound care specialist, if needed. LPA interviewed 10 residents of which 2 are incontinence. None of the residents interviewed stated that they have any injuries, wounds nor pain in the buttock area. Some residents interviewed also stated that they never develop wounds under facility's care. LPA reviewed the incident report submitted to CCL dated 01/06/2022 stating that R1 was being treated for the wound and under the care of a wound specialist. Report indicated that the wound specialist ordered R1 to be sent to the hospital because R1 was non compliant with the wound care plan. Based on documentation reviewed, R1 moved into the facility on 12/16/2021 and Preplacement appraisal information indicated that R1 has a history of skin breakdown and was diagnosed with moderate protein calorie malnutrition. Therefore there was insufficient evidence to corroborate with the allegation.

In regards to the allegation: “Resident was sent to the hospital without any medical records.” It is alleged that a resident was sent without any medical records to the hospital. No other details provided. Interviewed staff denied the allegation. Staff stated that mainly, it is the front desk receptionist who prepare the medical records prior to sending a resident to the hospital. Staff also stated that the emergency packet for the residents is located in the front desk and if receptionist is not available Med Tech on duty is responsible for providing emergency packet to paramedics. Interviewed residents denied the allegation and some residents stated that the office staff send them to the hospital with their medical records every time. Some residents also stated that if the facility did not provide it, they will hear it from the hospital personnel, but they never had that issue. Documents reviewed indicated that R1 was sent to the Hospital on 01/06/2022 and a staff provided EMT with R1's report, face sheet and medication list at 6:06pm. Therefore there was insufficient evidence to corroborate with the allegation.