Complaint Investigation Report

Allegations: “Due to staff neglect resident developed multiple pressure injuries while in care” and “Facility did not seek timely medical attention for resident with pressure injuries”

It was alleged that Resident #1 (R1) developed two (2) Stage II pressure injuries due to staff neglect and that facility staff failed to seek timely medical attention. Physician’s Report dated 05/22/2025 documented that R1 had coronary artery disease and was receiving hospice services at that time. R1 also had mild cognitive impairment but was able to follow instructions and communicate their needs. R1 had a history of skin breakdown, including an open skin impairment on the “butt and sacrum.” Resident Appraisal dated 11/24/2025 indicated R1 was non-ambulatory with a wheelchair and required assistance with transferring, repositioning, and incontinence care.

Interviews with staff and the ED revealed no documented reports or observations of pressure injuries, and staff denied the allegations. Staff stated they provided incontinence care and repositioned R1 every two (2) hours; however, their statements were inconsistent regarding R1’s repositioning schedule and whether R1 was bedbound. Approximately three (3) months prior to the allegations, R1 was discharged from hospice services. While on hospice, R1 received wound care for a wound staff reported had “healed.” Staff further reported that R1 experienced recurring redness and a dry, scabbing blister on the right buttock. Staff stated they applied “cream” and “ointment” to the area during incontinence care. Staff #1 (S1) reported observing an intermittent “small wound” approximately the size of a quarter prior to the allegations but could not recall whether this was reported to Administrators or Med-Techs. Staff #2 (S2) also confirmed that a pressure injury appeared to be developing but stated that lotion was applied and it “went away.”

According to the ED, staff are trained to report skin changes to Management, who then assesses the issue, notifies the resident’s physician and responsible party, and document the occurrence in the resident’s file. S1 stated they did not receive training on identifying pressure injuries. Staff #3 (S3) confirmed being notified of R1’s dry blister but could not recall the location of the blister or timing of the report. S3 stated that no follow up occurred because the blister was “dry.” S3 also reported that skin changes are not documented and that staff notifications are verbal only.