Complaint Investigation Report

Wound #2 Sacral is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed.

Wound #3 Left, Lateral Lower Leg is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed with presence of slough.

Wound #5 Right Buttock is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed.

Wound #7 Left Back is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed.

Wound #8 Right Hip is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed

Wound #9 Right Upper Back is a chronic Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed.

Wound #10 Left Back lower is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed.

Interviews with administrator revealed that although they had wound care nurse, they did receive information that R1’s wounds were not healing. Overall, the investigation revealed that although facility staff including the Administrator had knowledge that R1’s pressure injuries were not healing, they failed to take appropriate measures to ensure that there is no immediate threat to the health and safety of the resident.

Based on the information revealed from interviews and records review, there is sufficient information to support the above stated allegation. Therefore, the allegation is determined to be Substantiated at this time.

Exit interview conducted. Appeal rights given. Copy of report given.