Complaint Investigation Report

Facility staff had no documentation or record indicating that home health was contacted regarding the pressure injury. Facility staff were responsible for R1’s activities of daily living that included bathing/showering. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED.

The department investigated allegation, “Staff left resident unattended in 2 soaking wet diapers and a pad for extended period”. The department interviewed relevant parties and reviewed medical documentation. On 3/29/23 R1 was seen by home health to provide wound care. Home health worker observed R1 to be wearing three sets of diapers/briefs and two of three were wet. Home health worker indicates R1 was probably sitting in the wet depends for a couple of hours due to the amount of urine that was observed. The department interviewed administrator in which she stated resident was never in 2 depends, however staff do use a depend and a pad inside the depend during the night. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED.

As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D. Exit interview conducted.