Complaint Investigation Report

administration records and other relevant documents. Prior to this visit on (date) LPA reviewed R1’s medical records previously requested from the hospital.

Allegation: Resident developed pressure injuries while in care.

It was alleged that R1 developed pressure injuries while in facility care. Interviews with one (1) resident revealed they had no issues with pressure injuries. Interview with S1 stated that R1 is not on hospice or receiving home health services to get assistance for their pressure injuries. Facility staff are the ones assisting in changing the bandages and cleaning the wound. According to S1, they do not position or rotate R1. R1 is wheelchair bound resident and uses their heels to push and maneuver themselves around the facility using their wheelchair.

A review of R1’s medical assessment revealed they had no history or signs of skin breakdown as of 3.15.2025. On 04.14.25 R1 was admitted to the hospital for pressure injuries. Upon admission to the hospital, R1 had pressure injuries (PI) on their bilateral heel. The left (L) heel PI is unstageable, measuring 6x8.5cm. The right (R) heel is a Deep Tissue Pressure Injury (DTPI), measuring 2.5 x 3.5 cm.

Information received revealed that R1 developed health conditions requiring higher level of medical care (unstageable and dip tissue pressure injuries). R1 was not receiving home health or hospice care services, and the wound care was provided by facility staff, that were not skilled professionals.

Based on interview and record review it was concluded that R1 developed prohibited health condition and facility did not sought appropriate medical care. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the LIC 9099-D page.

Exit interview conducted. Appeal rights discussed. Copy of this report provided.