Complaint Investigation Report

The investigation, into the allegation, facility staff handle resident roughly when transferring causing pain, revealed the following. It was reported that when staff transfer Resident 1 (R1) they handle R1 in a rough manner that causes pain. Staff 1 and Staff 2 reported that R1 complains of pain when moving no matter how gently they assist. R1 reported that most movement causes them pain. The Administrator reported that no matter how slowly they assist or move R1 they complain of pain. The Home Health Nurse reported that R1 reports pain any time they are moved and assisted and they have observed staff and everything is being done to assist R1 in a safe comfortable manner. The Home Health Nurse reported that there doesn't seem to be a medical reason for the pain reported by R1 and they advised staff to be careful and gentle when moving R1. Based on the evidence gathered, the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation, into the allegation, resident developed a pressure injury while in care, revealed the following. Resident 1 (R1) moved into the facility December 16, 2023 and moved out of the facility on August 21, 2024. It was reported that R1 had a pressure injury that was caused by facility staff assisting R1 which caused them to remain in bed most of the time. R1 reported they enjoyed staying in watching TV. The Administrator reported they assist R1 into and out of bed every time they request it, R1 verified this report. Staff 1 and Staff 2 reported they always assist R1 into and out of bed when requested. The Home Health Nurse reported that R1 did have redness on the lower back but it never developed into a pressure injury and it was resolved. The Administrator reported that R1 had continuous Home Health visits for the duration of their stay. There is no record of R1 being diagnosed with a pressure injury. Based on the evidence gathered, the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, facility staff does assist residents with providing transportation for medical appointments, revealed the following. It was reported that the staff never have R1 ready to go to their medical appointments and when the transportation arrives R1 is not ready. Transportation cannot wait for R1 therefore they leave the facility and R1 ends up missing their appointment. Staff 1 and Staff 2 reported that R1 is always ready to go but R1's responsible party causes the delays and has changed the appointments at the last minute which has caused problems. The Administrator reported that R1 is always ready to go but R1's responsible party has caused issues by asking for R1's clothes or hair to be changed at the last minute, when R1 was already prepared to go. R1's responsible party denies the allegations.