Complaint Investigation Report

Wound was described as wound location: left trochanter, type of wound: consistent with pressure related injury, stage was listed as unstageable and wound size was listed as 4.2 x 4 cm. The left trochanter is located at the top of the left thighbone, on the outside of the hip. Interviews with staff were conducted and 5 of 6 staff indicated they did not observe any pressure injuries on R1. The sixth staff did not reveal knowledge of any pressure injuries. During staff interviews, 4 of 6 revealed R1 would pick at their skin causing small wounds. Staff would then clean and bandage the wounds. It was not clear during interviews where the wounds were located on R1. Narrative Charting dated 02/19/2022 corroborated staff interviews. The Narrative Charting revealed care staff reported R1 is pinching their skin, causing small wounds, the wounds were cleaned and bandaged. R1 was not able to be interviewed.

Based on interviews and records review the allegation of resident sustained an unstageable pressure injury while in care is unsubstantiated . A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

It was alleged that resident sustained injuries resulting in hospitalization due lack of care and supervision. R1 moved into the facility on 01/13/2022. R1’s Physicians Report dated 12/17/2021 indicated R1 was ambulatory. The Physician’s Report does not list R1 as a fall risk. R1’s AL Advantage Memory Care Resident Assessment was reviewed. The assessment is neither dated nor does it include R1’s name. However, the assessment was provided by the facility staff as relating to R1. The assessment indicates R1’s level of assistance as R1 was to receive (8) eight status checks per shift. Investigation did not reveal documentation of the eight (8) status checks per shift. Staff interviews revealed R1 was found on the floor. Staff interviews further indicated R1 was transported to the hospital on 02/08/2022 due to the un-witnessed fall. Medical records dated 02/08/2022 revealed R1 was noted with a contusion to the right elbow and the back of the right hand. R1 was discharged back to the facility on 02/09/2022. Narrative Charting dated 02/21/2022, revealed R1 was sent back to the hospital due to self-harm. Medical records dated 02/21/2022 revealed R1 had a chief complaint of agitation. Medical records for the 02/21/2022 hospital visit is where it was revealed an “anticipated” diagnosis of right hip fracture.

Based on interviews and records review the allegation of resident sustained injuries resulting in hospitalization due lack of care and supervision is unsubstantiated . A finding that the complaint is unsubstantiated means