Complaint Investigation Report

Allegation: Due to neglect, resident sustained pressure injuries

The allegation alleges that medical professional has concerns of neglect resulting in pressure ulcers.

During the facility inspection, LPA observed a caregiver transferring a resident from their wheelchair to their bed to relieve pressure. LPA observed a pressure cushion on the resident’s chair. The resident stated after activities the staff will assist them to their bed till the next activity or meal.

During file review, LPA received and reviewed resident R1’s Physician’s Report, dated 05/04/2024 that indicates no history of skin breakdown or condition. LPA received and reviewed R1’s Service Plan details dated 12/05/2024, that states Resident’s skin condition is normal, routine skin checks are conducted, and the use of pressure reduction cushions, mattress, boots, lotion, and creams, and assist with repositioning. A routine Wellness Observation was conducted on 02/28/2025, that indicates a full body skin assessment was completed and No lesions/symptoms were noted. Additionally, LPA reviewed Discharge/Transfer Progress Note dated 03/04/2025, that indicates Resident R1’s skin is intact at time of transfer. R1 was out of the facility from 03/04/2025 through 03/28/2025. LPA reviewed staff Progress Notes from 03/28/2025 through 03/31/2025 that indicated on 03/28/2025 at 9:19 PM R1 returned from the hospital and a skin check was performed, no pressure injuries were noted. Resident was kept clean and dry. On 03/29/2025 at 1:09PM, it was noted R1 was transferred from the bed to the wheelchair and then back to bed, and R1 was assisted with repositioning every 2 hours. Staff ensured resident was clean and dry. On 03/29/2025 at 10:32 AM, it was noted R1 was assisted with repositioning every 2 hours. On 03/29/2025 at 3:09PM, it was noted R1 was in bed and repositioned throughout shift, while family was at bedside. On 03/29/2025 at 9:59 PM, it was noted R1 was in bed and assisted with repositioning every 2 hours and was kept clean and dry.

During interviews with Staff S1-S8, were asked if any residents have been diagnosed with pressure injuries due to staff not assisting residents with repositioning, five (5) out of eight (8) stated no residents have sustained a pressure injury due to lack of repositioning.

During interview with Resident R2-R7, were asked if they have gotten any pressure ulcers or sores due to staff not assisting with repositioning, six (6) out of six (6) state stated they have not gotten any sores from not being repositioned and that staff are always available to help them reposition their bodies in bed, in their wheelchair, and even regular chairs.

During interviews with Witnesses W1-W3, were asked if their resident has sustained pressure injuries due to not being assisted with repositioning, two (2) out of three (3) stated they are not sure if the pressure injuries were caused from repositioning. One (1) out of three (3) stated there has been no concerns of pressure injuries.