Complaint Investigation Report

Investigation revealed the following: LPA review of R1’s records revealed post acute order summary indicated that R1 has orders for topical treatment to be applied to sacrum for pressure injury for 21 days. R1 had a wound with treatment at time of moving in to this facility on 02/16/2021 and moved approximately 30 days later. R1 was assessed for hospice services on 2/15/2021, on page 5 of 7 indicate existing wound/skin impairment but is not specific to what the skin impairment or wound is. It is alleged care staff the were not rotating the resident which resulted in bed sores. Review of the records indicate that R1 arrived to the facility under hospice care and had orders for wound care. Hospice noted dated 3/1/2021 report stage II pressure injury on sacro-coccyx ; altered skin status-t/t pressure injury on left posterior leg. There is no information revealed that will verify that the pressure injuries were the result of staff not turning the resident as they were documented to exist prior to moving into the facility. It is alleged that staff did not dispense medications as ordered. During the course of this investigation the medications and records had been removed from the facility. Interview with the facility administrator reports It was really hard to do physical care because R1 would reject meds and spit them out. There is no available documentation to support this information. It is alleged facility staff did not ensure that resident had an adequate amount of food and adequate amount of water. LPA tours and review of food supply did not reveal a deficit in availability of food and water for the residents on those dates. It is alleged that facility is increasing resident's fees without proper notice. Interview with administrator indicated that during the preadmission R1 was presented one way and after 30 day reassessment was needed and it was determined that R1 required more care than initially indicated and there was notification of a rate increase due to 30 day assessment of care needs.

We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.