Complaint Investigation Report

The investigation revealed the following: Allegation #1- Resident sustained pressure injuries while in care.

The details of the complaint alleged that the facility did not regularly rotate the resident every two hours as ordered in the resident's hospice plan, causing the resident to develop multiple pressure injuries on the back, bottom, arms, and legs. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Resident sustained pressure injuries while in care because the facility failed to rotate the resident every two hours. All staff stated that the resident was turned every two hours and repositioned. S1 stated that “all staff have had in-service training in how to care for hospice residents and pressure injury care was provided to this resident. Also, the resident had a history of skin breakdown prior to moving into our facility as reported in the LIC602, dated 07/07/2022”.

S2 stated that “the resident’s skin was brittle and bruised easily”. LPA reviewed the Turning and Repositioning logs and the Patient Visit Documentation log from hospice that corroborates their account that the facility was following the care plan for the resident. LPA reviewed the Physician’s report (LIC602) dated 07/07/2022, that reports the resident has a history of skin condition or breakdown and is very sensitive. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Resident sustained pressure injuries while in care. Residents stated that they did not have any problems with neglect from the facility.

Based on interviews and records reviewed there is insufficient evidence to support the allegation that Resident sustained pressure injuries while in care. 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 because the facility failed to follow the hospice care plan for the resident, therefore the allegation is Unsubstantiated .