Complaint Investigation Report

The investigation revealed the following:

Allegation: Facility staff did not seek medical attention for resident.

It is alleged that R1 was in need of wound care and facility failed to seek wound care to resident. Per interviews with R1’s family, upon visiting resident on 1/1/24 it was discovered that resident had wounds to right foot/toes and family were providing their own wound care for 3 consecutive days to resident until facility provided care. Per R1’s medical records and hospice nurse notes, injuries to toes/foot were minor and there were no signs of infection, hospice treatment to feet began on 1/3/24 and have been monitored during each visit. LPA observed R1 during initial visit on 1/3/23 and resident had a bandage on foot and hospice nurse was assisting resident, during todays visit LPA interviewed R1 and resident stated that their foot got the proper care, can now wear socks and that caregivers and nurse have been treating their foot on a daily basis. Resident was observed to be wearing clean socks and shoes during visit. Interviews with staff 5 out of 5 staff stated that while assisting with ADL’s staff did not observe the wounds to R1’s feet prior to 1/3/24 but have since then been making sure wounds are being treated and have undergone an In-service training dated 1/3/24 that covered care and monitoring of R1’s right foot and toes. Interviews with residents, 5 out of 5 residents stated that they get the proper medical treatment and staff are helpful when they have any need for medical assistance.

Allegation: Facility staff did not notify resident's responsible person of wounds requiring medical attention.

It is alleged that Responsible Party (RP) was not notified of wounds to R1’s feet or medical attention needed to residents’ feet. Per RP they were never notified of foot treatment needed for R1. Per staff interviews 5 out of 5 staff stated that they were unaware of R1’s foot condition prior to 1/1/24, facility contacted hospice regarding R1’s feet and hospice provided foot care to resident on 1/3/24, after it was brought to staffs attention by RP during a visit. Per hospice staff the injuries to feet were minor and did not need immediate medical treatment. Last hospice visit prior to 1/1/24 was on 12/28/23 and per hospice staff there were no signs of foot treatment needed at that time therefore no contact to responsible party was given.