Complaint Investigation Report

Regarding the allegation: Staff do not meet resident's incontinence care needs in a timely manner, resulting in resident sustaining multiple pressure injuries. It is being alleged that resident #1 (R1) waits for an hour or two (2) before a staff comes to help them and they developed pressure injuries. During LPA’s interview with R1, R1 stated, “I don’t get changed often and I am left in soiled diapers waiting for a staff.” LPA asked when do they change you and R1 stated, “only in the morning and before I go to bed.” LPA obtained a copy of incontinence residents and R1 is supposed to be changed four (4) times a day and during the nocturnal shift (NOC). During LPA’s physical tour, R1 was observed spending most of their day out of the facility. LPA conducted another interview with R1 on 05/12/26 and observed them out of their room during incontinence scheduled. When questioned as to why they are not in their bedroom and/or in the facility during the scheduled incontinence changes, R1 stated, “I don’t use the bathroom much so I just decide to stay in my diaper.” LPA asked R1 if they wanted to go to the hospital so they can get re-evaluated for all their concerns, R1 stated to LPA, “they are not going to the doctor, they are doing fine and their wound is doing much better.” LPA did obtain Home Health notes for R1 on 05/04/26 and it was determined that R1 developed a stage 3 wound on their buttocks area on 03/23/26. Furthermore, LPA interviewed one (1) of the Home Health case managers regarding R1 and they stated, “R1 did have a stage 3 in their buttocks area but it is now healed.” Let it be noted, R1’s admission to the facility was on 01/27/26 and was discharged from the health care center on 01/26/26 with no wounds. Furthermore, LPA interviewed three (3) facility staff that confirmed R1 does not like to be touched and refuses to go to the hospital for anything that they have complained about. LPA's interview with the Licensed Vocational Nurse stated, "R1’s wound now looks like a stage 1 and not a stage 3 wound anymore.” Therefore, based on the home health records of wound care and the refusal of R1 to be changed per the incontinence schedule, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time.