Complaint Investigation Report

Staff revealed that they always keep juice and water next to R1’s bed and that R1 was drinking fluids regularly. A review of medical records from the home health care agency revealed that R1 had no signs and symptoms of dehydration. A review of hospital records did not reveal any information to verify that at the time of admission to the hospital R1 was dehydrated.

Based on interviews and record review, there is no sufficient evidence to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff neglect led to resident sustaining multiple pressure injuries

It was alleged that Resident #1 (R1) developed stage three (03) injuries while in care of the facility. During the investigation, on 03/27/2023, IB investigator conducted interviews with facility staff and residents. On 05/02/2023, IB investigator conducted interviews with other witnesses. On 05/03/2023, IB investigator reviewed medical records previously requested from the home health agency and the hospital.

Staff revealed that R1 never had stage 3 pressure injuries prior to R1’s hospitalization on 08/28/2022.

A review of home health records verified the information revealed from staff.

Upon review of hospital record, no medical information was noted to conclude that R1 had Stage 3 pressure injuries at the time of admission to the hospital on 08/28/2022.

The medical records and interviews revealed consistent information that R1 was admitted to the hospital with stage three (03) pressure injury. Based on interviews and record review, there is not enough evidence to support the allegation that there was a lack of care resulting in R1 developing a stage three (03) pressure injury. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff mismanaged resident's medication

It was alleged that staff stopped giving the resident’s prescribed medication without doctor’s consent. To investigate the allegation, on 02/27/2023 at 10:30 AM, LPA Duguma requested documents and interviewed three (03) staff between 11:30 AM to 1:00 PM. On 10/10/2023 at around 12:00 PM, LPAs interviewed two (02) out of four (04) residents.