Complaint Investigation Report

at R1’s admission, and R1 was discharged same day with only instructions on how to prevent wounds.

On 04/17/25, LPA called and interviewed hospital staff, who confirmed R1’s hospitalization on 04/10/25. Hospital staff stated R1 was admitted and assessed. No wounds noted. R1 was discharged same day.

On 04/17/25, call from R1’s family to confirm R1 had not wounds assessed during hospital visit on 04/10/25. R1 was discharged back to the facility with no new orders.

In addition to interviews, review of R1's record do not indicate any wounds or skin breakdown. Copy of instructions from the hospital given to R1 at discharge, on how to prevent wounds was obtained. No new orders given.

Based on the information obtained, there isn't enough evidence to corroborate the allegation of staff not repositioning R1 as needed causing pressure wounds to worsen. Therefore, the allegation is deemed Unsubstantiated at this time.

In regards to the allegation, it was reported that staff have been mistreating R1 and speaking to R1 inappropriately. The complaint report that is received indicated that staff would "treat the resident like a dog" and command him to "Eat!" There were no witnesses identified to confirm this allegation. Interviews with the administrator and staff deny the allegation. The administrator added that it could have just been a language barrier as some of the facility staff are of different nationality. Staff could have just been encouraging the resident to eat and no insults were intended. Interviews with five (5) out of five residents also deny the allegation of staff mistreating them or being inappropriate towards them.

Based on the information obtained, there wasn't enough evidence to corroborate the allegation of staff speaking inappropriately to resident(s). Therefore, the allegation is deemed Unsubstantiated at this time.