Complaint Investigation Report

The investigation included the following:

During initial vist conducted on 1/3/24 LPA obtained copies of Resident and Staff Rosters and copies of documents within Resident #1’s (R1) file including: Admission Agreement, Identification and Emergency Information, Current Physician's Report, Appraisal and Appraisal/Needs and Services Plan, Copies of Most Current Nursing Home Podiatrist Visits, Hospice Information and Communication Log. LPA toured R1’s room and observed R1 to be clean, well groomed and social.

During subsequent visit dated 1/11/24 LPA interviewed 5 Staff, 5 Residents, R1's Power of Attorney, and Hospice Staff. LPA also interviewed the Responsible Parties of the 5 Residents interviewed.

The investigation revealed the following:

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

It is alleged that, "the resident's toes are "raw and bloody", "infected" and "toe nails are coming off", and 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/shower logs dated 12/21, 12/26 & 12/28, R1 had a complete shower with no signs of injuries and/or signs of pain noted by staff. Per interview with R1's hospice nurse, treatment to feet began on 1/3/24 and have been monitored during each visit, injuries to toes/foot observed on 1/3 were minor and there were no signs of infection. 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.