Complaint Investigation Report

Regarding the allegations: Resident sustained multiple injuries while in care

It was alleged that upon being admitted to the hospital, R1 was admitted with pressure injuries. R1’s physician’s report dated 11/5/2021 and R1’s service plan (date unknown) did not indicate that R1 had any wounds or injuries prior to being admitted to the facility. Facility records noted that R1 was receiving home health services while residing at the facility; however, records indicated that R1 was discharged from home health services on 11/29/2021 due to lack of funding due to insurance changes. Home health records indicated that on 11/16/2021, R1 was found with a pressure injury on the heel and possibly one on the coccyx. In addition, whereas staff claim that residents are regularly repositioned as needed, there were no records or evidence to indicate whether R1 was regularly repositioned. Upon being admitted to the hospital on 12/2/2021, R1 was found with the following pressure injuries: unstageable pressure injury on the left plantar heel, stage 3 pressure injury on the left buttocks, right ear lesion, and right heel blanchable. There was no evidence of an exception to retain R1 on file, nor was R1 receiving hospice services.

Based on the information obtained, there is sufficient evidence to support the claim that R1 sustained multiple injuries while in care. This allegation is deemed Substantiated at this time.

Regarding the allegation: Insufficient staffing

It was alleged that at the time the complaint was received, the facility had insufficient staffing due to staff being fired and/or quitting. As a result, resident care needs were let un-met. Staff interviews revealed that the licensee indeed let go of staff due to the challenges and complaints that were received from resident’s family members. Staff also claimed that management staff would step in and provide care for the residents when there were an insufficient number of caregivers or medication technicians on the floor. Yet interviews with former and current staff confirmed that there often are a lot of call-offs and admitted that resident needs could not be met. Staff confirmed that due to lack of sufficient staffing, they have not followed the care plan for Resident #4 and Resident #5 (R4, R5) both whom require two-person assist for transfers. Staff also noted that they had worked alone in the facility due to insufficient staffing. In addition, a facility file review revealed that on 12/31/2021 and 2/23/2022, Resident #6 (R6) eloped from the facility while in care due to lack of care and supervision.

Based on the information obtained, there is sufficient evidence to support the claim of insufficient staffing. This allegation is deemed Substantiated at this time.