Complaint Investigation Report

On 7/19/23, LPA Maldonado conducted a telephone interview R1's RP. During today's visit, LPA Maldonado interviewed Residents# 2-4 (R2-R4), Staff# 1 and 4 (S1, S4), conducted a telephone interview with Staff# 5 (S5), and attempted telephone interviews with Staff# 2, 3, and 6 (S2, S3, S6). However, LPA was unable to reach them for interview. LPA was unable to interview R1 due to R1 no longer residing at the facility. The investigation revealed the following:

Regarding allegation- Resident sustained multiple pressure injuries while in care.

It is alleged that R1 was hospitalized on 1/06/22 and was noted to have multiple wounds including a stage 2 pressure injury on R1's buttock. Per interviews conducted, (4) of (4) staff denied allegations of R1 having a pressure injury and stated to be aware of R1's wounds, that were a result from R1 being hit by a car on 12/11/21 while R1 was out of the community. Staff stated the wounds were also related to R1 falling into a bush on an unknown date, as it occurred outside of the community, per R1's statements to staff when questioned. These wounds were already being treated by the facility nurse. R1 notified facility staff upon R1's return to the home and facility staff immediately called 911. Paramedics arrived to the facility and recognized R1, as they stated they had rendered help to R1 earlier that day, as they arrived to the scene where R1 had been ran over. Paramedics indicated R1 was assessed and refused additional medical care by stating to be okay and left the scene. Per interview conducted with HN, it was discovered that none of R1's wounds were pressure injuries and did not require staging. All wounds were noted to be healing and appeared to be old. IB Investigator deemed this allegation to be Unsubstantiated. LPA agrees with findings.

Regarding allegation- Staff did not report unusual incidents to resident's representative.

it is alleged that R1's RP was not notified about the incident of R1 getting hit by a car or R1's injuries sustained. Per interview conducted with RP, RP reported that RP has no notes and no recollection of facility staff notifying RP about the incident where R1 was hit by a car while out in the community, or about the injuries sustained due to the incident. RP was not aware until the hospital called RP to notify about the incident and injuries. Per interviews conducted with staff, (3) of (6) staff interviewed denied the allegation, stating that the facility policy is to always notify all resident's responsible parties of any incident occurred with the resident, regardless of it happening there or out in the community. Per S1 and S2, R1's RP was contacted and notified of the incident. Per a copy of an email received, dated: 1/21/22, by S1, it is noted that S1 stated in the email that the incident occurred was discussed with R1's RP, who informed S1 would contact the hospital to obtain more information regarding R1's hospitalization. Per incident reports obtained, it is noted that they all indicate that R1's RP was notified of this incident and separate incidents occurred at the facility. Per interviews conducted with residents, (3) of (4) residents could not corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was held. A copy of this report and appeal rights were provided to the Administrator.