Complaint Investigation Report

-- Staff did not follow resident's care plan for repositioning

-- Due to improper care client developed pressure injuries.

In regard to the above allegations, it was reported that the facility staff was not following client #1 (C1)’s care plan to turning C1 as frequently as they should have, therefore causing a pressure injury specifically on the heels and buttocks. The stages of the pressure injuries were not disclosed. Interviews with four (4) of four (4) staff reveal that C1 does not have any pressure injuries greater than a stage II. Staff also reveal that they follow C1’s need and service plan and are reposition C1 every two (2) hours. Review of C1’s records reveal that C1 is receiving home health care. Home health records indicating Stage II pressure injuries at the coccyx area and heel being treated by home health, podiatrist, and facility staff. No indication on file that C1 has anything greater than a stage II injury. Per records, present pressure injuries were healing. A review of C1’s facility records, including need and service plan, verified that staff has been changing R1's diaper and repositioning C1 every two hours. Based on the information obtained, interview, and record review, there was insufficient evidence to verify that C1 developed a pressure injury due to improper care and staff not following C1 care plan to reposition. Therefore, the allegation is deemed Unsubstantiated at this time.

-- Staff did not provide incontinence care to resident as needed

It was alleged that staff are double diapering C1. During the physical plant tour, LPA did not experience any malodor and observed that all residents were clean and well groomed. During interviews with the administrator, staff S4 and Staff S5 stated that they change C1 diaper every two (2) hours when re-position them and more if needed. S4 and S5 also stated that they do not put on more than one diaper at a time. At 12:42 pm, LPA observed staff repositioning C1 and did not observe C1 having a double diaper.

Based on interviews and observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No immediate health and safety hazard is noted during this visit.

An exit interview was conducted, and a copy of the report was issued.