Complaint Investigation Report

healthcare progress notes/summary from Brittany House & Shoreline Healthcare Center dated 4/28/2023, and Specialty Hospice Care records dated 8/5/2024 - 10/11/2024. LPA also conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - 8 (R1–R8), Witness 1(W1) and attempted to interview Resident 9 (R9) who no longer resides at the facility.

#1- Allegation: Resident sustained an unstageable pressure injury due to lack of care from staff.

On 5/12/2025, at 11:00 AM, LPA Allen conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members denied knowing if R1 suffered from a pressure wound or whether an outside agency was providing wound care. LPA interviewed Residents 1 - 8 (R1–R8). Of the 8 residents, 2 stated that they do not have any pressure injuries, The remaining 6 residents were unable to engage in a clear conversation, and LPA did not observe any visible pressure injuries on residents. W1 stated there was a pressure injury caused due to lack of care but could not provide evidence to corroborate the allegation.

LPA reviewed R9’s facility file and found hospice records from Specialty Hospice confirming services were provided 2x/week from 06/14/2024 - 10/11/2024, and The Wound Pros provided care 1x/week from 8/5/2024- 10/11/2024. The needs and service plan dated 4/28/2023 - 10/16/2023 does not indicate the presence of a pressure injury. LPA could not obtain sufficient evidence to substantiate that R9 sustained a pressure injury due to a lack of care by facility staff.

#2- Allegation: Staff did not provide resident's medication as prescribed

On 5/12/2025, LPA conducted interviews with Staff 1- Staff 10 (S1-S10), of those interviewed, 10 out of 10 stated that all residents are given their medications as prescribed by their physicians. On 5/12/2025 LPA reviewed R9’s file and found no records to verify whether R9 received their medication as prescribed. On 5/12/2025 and 5/22/2025 the Medication Administration Records (MARS) could not be provided for R9 therefore, LPA was unable to verify if their medications were given or not.