Complaint Investigation Report

The investigation revealed the following:

Allegation: Resident sustained multiple pressure injuries while in care.

IB investigator reviewed R1 medical records and conducted interviews with witnesses and facility staff. Review of Hospital records and photographs document a sacral area and a perirectal area wound. However, there is no information that these wounds were formally staged. The first charting of the sacral area wound was not until R1 had been hospitalized for approximately 34 hours. Information obtained from Witness #1 (W1) supports the possibility that the wound could have developed in the hospital, not necessarily while in the care of Vista Del Mar. Review of R1 facility record does not document pressure injuries or wounds. The Administrator and facility staff were interviewed and denied R1 having multiple pressure injuries.

Allegation: Resident sustained multiple falls while in care.

IB Investigator interviewed W1 to obtain professional opinion is that R1 did sustain multiple witnessed falls is June and July which were not reported by the facility but did not see any evidence there were multiple unreported falls suffered by R1 . LPA Calderon interviewed S1-S4 and all confirm that R1 did have falls due to age, not waiting for staff while moving from wheelchair to bed. According to records reviewed R1 required prompts to not move out of wheelchair or bed with out assistance due to R1 dementia. The facility conducted a fall risk assessment in conjunction with R1 family and the falls were being addressed.

Allegation: Staff did not give resident medication as prescribed.

It is alleged staff did not give resident medication as prescribed. LPA Calderon interviewed S1-S4 all confirm that R1 medication was given correctly and there was no mistake with R1 MAR. LPA Calderon interviewed R2-R11 and all confirm no issues with medication and staff does a great job. LPA Calderon reviewed resident medications and Medication Administration Record and did not observe any discrepancies.