Complaint Investigation Report

Records reviewed revealed that C2 has a history of skin integrity issues. C2 has a reoccurring Stage 1 ulcer on the buttocks from insufficient circulation to the area. The facility has a restricted health care plan on file for pressure injuries. Interview with the LVN from Excellence Home Health indicated that C2 had 2 pressure injuries on the buttock. One of the wounds has healed and the other wound is healing well. Repositioning logs were reviewed and documented that C2 is repositioned regularly. Interviews with staff revealed that C2 is repositioned every 2 hours and C2's wound is healing well. Regional center representative did not have any concerns about the wounds and confirmed home health visits C2 regularly. During today's visit, LPA reviewed Excellence Home Health notes dated 01/12/2023 stating that C2 bilateral buttocks noted to be clear, will continue on skin maintenance to prevent future breakdown. Based on the records and interviews there is insufficient evidence to prove the pressure injury developed due to neglect.

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.

Exit interview held and a copy of the report was provided