Complaint Investigation Report

Regarding the allegation that facility employees neglected or failed to provide an appropriate level of supervision which resulted in Resident#1(R1) developing blood clots in their lungs as well as pressure injuries on their ears and buttocks, IB Investigator Real interviews revealed the facility residents had no complaints and a family member of one resident interviewed reported being happy with the level of care being provided by the facility. The facility employees denied the allegation. R1 left the facility on 1/5/24 and was seen in the hospital on 1/6/2024 with no marks or injuries identified. R1 was diagnosed with pneumonia and no abuse or neglect concerns were noted in the records. On 1/7/2024, R1 was readmitted to the hospital and diagnosed with blood clots in their lungs and a UTI. On 1/8/2024, R1 was transferred to another hospital for further treatment and it was reported that R1’s family member spoke with R1’s hospital doctor and reported abuse concerns alleging that R1 was never moved and left in bed at all times. The doctor concluded that R1’s immobility (as reported by R1’s family member) most likely led to the blood clots in their lungs. R1’s family member was interviewed and did not recall telling anyone R1 was not moved and in bed at all times while they were residing at the Azalea Gardens facility. R1’s hospital doctor was interviewed and could not definitively identify the cause of the R1’s blood clots. The doctor also advised R1 had no pressure injuries on their ears or buttocks, but R1 had a blister on their buttocks and a small bilateral bruise on each ear of unknown cause. The information and evidence obtained did not sufficiently support the allegation, thus based on the information obtained and the interviews conducted the allegation is deemed Unsubstantiated.

Exit Interview Conducted. A copy of this report provided.