Complaint Investigation Report

ALLEGATION #1: Staff neglect led to resident sustaining pressure injury.

ALLEGATION #2: Resident sustained unexplained injuries.

The details of the complaint alleged due to staff neglect resident #1 (R1) sustained pressure injuries. The complainant observed on 06/23/24 a bruise on the chest and right arm (R1). Several weeks back the complainant also observed a bed sore on (R1’s) buttock area. The complainant reported the staff were unable to explain the reason for the bruises and bed sore when inquired. The complainant was not available to provide further details on this allegation.

Investigation revealed (R1) was admitted to Angel’s Haven II on 01/05/24 in accordance with the Admissions Agreement (dated: 01/05/24). (R1) received hospice care from Divine Hospice Services, Inc., effective 01/07/24.

On 07/03/24, between 09:00 am – 10:15 am, the Department interviewed (4) out of (4) residents #1-#4 who denied having sustained any bruises or pressure injuries while in care. (R1) claimed to have no bruises on the chest and arms nor a bed sore on (R1’s) buttocks area. (R1-R4) are complimentary of staff and the care and assistance they all receive from each of the staff.

On 07/03/24, between 09:30 am – 10:45 am, the Department interviewed (3) out of (3) administrator #1(A1) and staff #1-#2 (S1-S2) claimed this allegation was false. (A1 and S1-S2) stated no residents in care have sustained any bruising or pressure injuries while in care. (A1 and S1-S2) claimed that (R1) is under hospice care with Divine Hospice Services, Inc., and it is under medical professionals with a registered nurse (RN) and licensed vocational nurse (LVN) twice a week. (A1-S1) claimed the facility staff was only responsible for (R1)’s non-medical care since the facility is a non-medical care facility. (A1 and S1-S2) pointed out that although they are not trained medical professionals, the facility staff is capable of caring for and supervising residents. (R1) is not bedridden and can reposition in bed, according to (A1-S1).

On 07/03/24, between 02:28 pm – 02:45 pm, the Department interviewed (5) out of (5) witnesses #1 - #5 (W1-W5) denied residents ever sustained bruises or pressure injuries while in care. (W1) a registered nurse (RN) from Divine Hospices Services confirmed that (R1) has been under hospice care since 01/07/24 and that this accusation is false. (Evaluation Report continues LIC 9099-C)