Complaint Investigation Report

Allegation: Resident sustained an injury due to staff neglect. – Substantiated.

According to interviews conducted, R1 sustained an injury while in the facility on 02/05/2023. R1 sustained a burn the size of a half dollar on R1’s left leg. The Department received an unusual incident/injury report on 2/12/2023 . Incident report indicated on 02/05/2023 staff were changing R1 prior to bedtime and observed blisters on R1’s left leg from the knee to mid-thigh. Staff provided first-aid and contacted EMT to request an urgent assessment and send out to the hospital. R1’s Power of Attorney (POA) and primary care physician were contacted as well as Executive Director. R1 refused to be transported to the hospital and POA agreed. Although R1’s burn was unwitnessed, interviews with staff and witnesses determined that R1 was burned from an electric fireplace that was located on the floor in the common area of the facility.

On 02/07/2023, R1 was taken to the hospital due to high blood pressure and the burn wound appeared to be at risk for infection. R1 returned to the community the same day with wound care orders and supplies. The facility was to monitor R1 for pain or any signs or symptoms of infection. The facility nurse was to reassess the wound healing progress at 7 and 14 days to ensure proper treatment is being administered. Wound dressing changes were to be performed by Med Techs on shift, all of which had been properly trained on the wound cleanse and dress process. Medical records indicated that the R1’s burns were second and first degree burns to lateral left lower leg, knee, and thigh. At the time of R1’s hospital visit on 02/07/2023, burn did not show signs of infection and R1 is stable for discharge back to memory care facility. On 2/08/2023, R1 returned to the hospital concerning burn care. The hospital provided R1 with bacitracin, gauze, and nonadherent and tape and R1 returned to the community. On 2/13/2023, R1 returned to the hospital for re-evaluation of burn wounds. R1 diagnosed with third degree burn on left leg and will require daily wound care. R1 was discharged from the hospital and admitted to skilled nursing facility on 2/15/2023.

R1 was admitted into the facility on 10/12/2021. The Department requested and reviewed R1’s physician’s report that was completed on 09/15/2021. According to R1’s physician’s report, R1’s primary diagnosis is progressive supranuclear palsy (PSP) and secondary diagnosis is dementia and Parkinson's. R1 cannot manage their own treatment, medication, and equipment. R1 has visual impairment, bowel impairment, bladder impairment, and motor impairment/paralysis. R1 uses an assistive device such as a walker and cannot walk unassisted. R1 is confused/disoriented and cannot locate self temporally or spatially. R1 has wandering behavior and is not able to leave the facility unassisted. R1 is non-ambulatory based upon both physical and mental condition. Facility completed R1’s personal service plan on 10/09/2021.