Complaint Investigation Report

LPA conducted (2) staff interviews with staff who cared for R1. (2) of (2) staff revealed R1 was bedridden and unable to turn or reposition themselves in bed, and was turned every (2) hours. They revealed staff made attempts to get R1 out of bed but R1 was unable to tolerate it. (1) of (2) staff revealed a Hoyer lift was not used on R1 as R1 would yell out in pain due to a sore on their body.

Admission agreement and Hospice visit notes for R1 revealed R1 resided at the facility from 11/21/2022 to 12/24/2022. R1’s Hospice Care Plan from 11/21/2022 revealed R1 had a pressure injury on their bottom and was bedbound. Hospice equipment list revealed a Hoyer lift was ordered 10/31/2022, prior to R1 being placed at the facility when they were deemed non-ambulatory.

The facility’s internal “Two-hour Turn Log to Prevent Skin Breakdown” was documented every (2) hours for the resident during R1 stay at the facility.

Therefore, the allegation that R1 was not provided with the opportunity to be out of bed is unsubstantiated at this time. 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, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.