Complaint Investigation Report

Allegation: Staff did not adequately assist resident with repositioning.

The complaint allegation alleges that due to not being repositioned frequently resident has developed redness on the sacrum and a blister on their heel.

During record review the department received and reviewed R1’s Physician Report dated 07/26/24 that indicated the resident is nonambulatory. Additionally, the Physician’s Report indicated R1 requires Continuous Bed Care, requires assistance with Incontinence, and is unable to transfer independently.

Additionally, during record review the department received and reviewed R1’s physicians request for home health services dated 09/12/24. On the referral, the department observed, R1 was diagnosed with a “pressure ulcer of left heel stage 1.”

During the facility tour, the department observed a board in the Medication Room that indicated Alert Charting that had R1 listed for wounds on both heels. Additionally, the department observed a Reminder Schedule for all shifts to assist R1 with repositioning or transferring, and incontinence care every two (2) hours.

During record review, the department received and reviewed staff training logs from Relias for five (5) Staff. The department observed five (5) out of five (5), have had trainings including The skin and Pressure Injuries, Proper Positioning, and Recognizing and Reporting Skin Conditions.

During interviews with Staff S1-S10, were asked how often a resident who requires assistance with repositioning is assisted, ten (10) out of ten (10) stated they help residents reposition every 2 hours. Additionally, Staff S1-S10 were asked how frequently residents are checked for pressure injuries, ten (10) out of ten (10),