Complaint Investigation Report

The investigation revealed the following: Regarding the allegation: Staff did not tell authorized representative of change in resident's condition. “ It’s being alleged that the facility staff did not notify reporting party that a resident had a pressure injury.” During interviews with residents: 0 out of 7 could not confirm this allegation to be true. on 05/16/2022 at 11:20am R1 states, “I’m not sure if my wound was reported.” On 06/072022 at 10:28am R2 states, “if it’s serious enough they will call the paramedics and then my daughter. It has happened about 3 or 4 times. They are right on top of it. I can’t complain about my care at all here.” On 06/07/2022 at 10:42am R4 states, “I don’t know how many times I’ve gone to the hospital, but they have told my family every time.” On 06/07/2022 at 10:55 am R6 states, “yes they notify my family if there is a change in my health condition.” On 06/07/2022 at 11:01am R7 states, “yes they communicate very well here.”

During interviews with staff, 0 out of 6 could not confirm this allegation to be true. On 05/16/2022 at 11:12am S1 states, “we always communicate if there is a change in conditions of a resident.” On 06/07/2022 at 11:09am S2 states, “yes that’s my job and vice versa. The staff report to me and I follow up. For R1 it wasn’t a pressure injury or sore. It was like a scratch that would come and go.” On 06/07/2022 at 11:26am S5 states, “yes of course. First, we call our supervisor and then the family. The supervisor calls the families. R1’s family knew because S2 made contact.” On 06/07/2022 at 11:31am S6 states, “I’ve worked here for 2 months and from what I have seen they do report changes to the families.”

Regarding the allegation: Resident received a pressure injury while in care. “ It’s being alleged that a resident developed a pressure injury while in care.” During interviews with residents: 6 out of 7 could not confirm this allegation to be true. 1 out of 7 confirmed the allegation to be true. On 05/16/2022 at 11:20am R1 states. “I got this wound because they were leaving me wet at night.” On 06/07/2022 R2-7 all state not knowing of any residents having or had a pressure injury. They also stated not having any pressure injuries themselves.”

During interviews with staff, 0 out of 6 could confirm this allegation to be true. On 05/16/2022 at 11:12am S1 states, “we didn’t know about an open sore until R1’s relative reported it. The staff reported not seeing any open sores.” On 06/07/2022 at 11:09am S2 states, “for R1 it wasn’t a pressure injury or sore. It was like a scratch that would come and go. The staff mention that it was a scratch. It was not something that was alarming.” On 06/07/2022 at 11:17a S4 states, “I gave her a shower and saw that she had a scratch. I asked