Complaint Investigation Report

The investigation revealed the following: Regarding the allegation… Due to neglect residents developed pressure injuries while in care. “It’s being alleged residents are left unattended in their rooms, not turned constantly, leading to open bed sores.” LPA interviewed 4 out of 45 staff in total. 0 out of 4 staff confirmed the allegation. S1 states, “there is only one person that’s on hospice. They have a small pressure wound and are receiving wound care from hospice. I want to say it’s at stage 2 right now.” S2 states, R1 has a wound that is just forming due to being bedridden, and she’s on hospice. The wound is very small. Hospice is taking care of the wound with me. I take care of it as well as hospice. I don’t think there are any other residents with a pressure ulcer.” S4 states, “the nurse takes care of the wound and we reposition every two hours. I don’t think the residents are neglected.”

During interviews with the resident, LPA Agard attempted interviews with 11 out of 89 residents in total. 0 out of 9 residents confirmed the allegation. 2 residents were unable to participate in the interview due to their cognitive ability. R2 states, “I haven’t observed anything like that. I’m never neglected, and I have a good time here. Everything is fine here with the girls.” R4 states, “no. I don’t know about that. People fall but that’s about it. I’ve never seen anything except for maybe a cut from a resident falling. I don’t feel like anyone is neglected here.” R6 states, “I don’t know anything about that claim.” R8 states, “I don’t know about any pressure injuries and no one is neglected from what I can see because I watched them.”

Regarding the allegation… Residents are left soiled for extended periods of time while in care. “It’s being alleged many residents are left sitting in wet diapers and clothing.” 0 out of 4 staff confirmed the allegation. S1 states, “our residents are checked every two hours. That’s our standard. We don’t have an actual incontinent schedule. We have to check everyone regardless. We check their diapers, briefs and offer assistance to the restroom.” S2 states, “I have not observed that. The caregivers check every two hours if they are soiled. It doesn’t matter if they are bedridden or incontinent. They have to be clean before going to breakfast.” S3 states, “residents aren’t left wet or soiled. We always try to change them every 2-3 hours. Especially the ones with sensitive skin. We know the incontinent people and the people that need more attention.” S4 states, “I don’t think so. The policy is that we need to assist each resident so we can’t leave the residents wet for long periods of time. We check every 2 hours. With some residents I check every 30 minutes.”