Complaint Investigation Report

Water temperature was tested in each residents room and tested between 108.0 -109.2 degrees F., which is within the required 105-120 degrees F. LPA reviewed and requested copies of resident #1(R1)'s file. LPA interviewed Administrator. No health and safety hazards were observed during visit.

LPA reviewed and obtained resident’s hospital records, home health records, and other pertinent medical information. LPA also reviewed the department’s investigation reports.

LPA interviewed five (5) staff and five (5) residents.

Allegation: Staff neglect resulted in a resident sustaining multiple pressure injuries . It is alleged that facility staff neglected resident which caused resident to develop pressure injuries.

The investigation revealed: LPA interviewed five (5) staff, and three (3) of five (5) staff denied the allegation, stating they were not aware of the allegation. Two (2) staff stated they reported the wound(s) to their supervisor who no longer works at facility. LPA interviewed five (5) residents, and all five (5) residents could not corroborate the allegation. The department investigated this allegation and presented the following. The resident moved into the facility on 9/11/2024 with no pressure injuries. He was identified as needing full assistance with bathing and dressing in the resident assessment dated 09/11/2024. Caregivers did not observe or address the wounds during bathing and dressing tasks. On 11/16/2024 the resident was discovered with an open wound pressure injury on resident’s sacral area that was described as stage 3 wound by an Agency Med Tech who saw the resident’s wound the day of discovery. The resident was admitted to the hospital on 11/19/2024 and was diagnosed with an unstageable pressure injury on his sacral area. In addition to the sacral pressure injury, deep tissue pressure injuries (DTIs) were discovered on the victim’s right hip, as well as on his left and right heels, and feet. Facility caregivers failed to provide an appropriate level of care and supervision resulting in pressure injuries. There is enough evidence to prove that facility staff neglected resident causing resident to sustain pressure injuries.

Allegation: Lack of supervision lead to multiple falls resulting in injuries. It is alleged that resident had multiple falls that led to injuries. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. LPA interviewed five (5) residents, and all five (5) residents could not corroborate the allegation. Resident had been residing in the Baldwin Gardens Skilled Nursing facility from 12/24/2023 until 9/11/2024. The resident was sent to Arcadia USC Hospital on 7/15/2024 and a CT of the victim’s head was done. The CT scan revealed no injuries, and no subdural hematomas were found on the CT scan. After returning to the SNF the resident was placed onto one-on one supervision for the remainder of his time there and resident had no further falls. Records revealed the resident had two falls while residing at the facility, the first fall occurred on 9/14/2024. (CONTINUED)