Complaint Investigation Report

Documentation also shows that staff assessed R1’s mobility, encouraged transfers to a wheelchair, and educated R1 about the importance of repositioning to prevent further injury. Despite these efforts, R1 at times declined repositioning or participation in mobility activities. Hospice records from September 2024 confirm that nursing assessments found no pressure ulcers and that pressure injury prevention measures were reinforced. Interviews with facility staff and review of assessments demonstrate that staff followed R1’s care plan, provided incontinence care, and made timely notifications to family and healthcare providers regarding skin concerns. There is not preponderance of evidence that staff did not take reasonable steps to prevent pressure injuries; therefore, the allegation is UNSUBSTANTIATED.

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Allegation: Staff are retaining a resident who needs a higher level of care –

The investigation into this allegation consisted of interviews and record reviews. A review of R1’s records shows that staff consistently monitored R1’s needs, communicated with family, and sought medical input when concerns arose. Care notes indicate that staff contacted R1’s physician and family regarding R1’s skin condition, offered daily assistance with transfers, and adjusted care plans in response to changes in R1’s condition. Documentation further shows that R1 was regularly assessed, including a semi-annual assessment on 8/27/24, which confirmed that R1’s care needs remained within the facility’s scope of services. When R1’s condition began to change, staff appropriately discussed the option of hospice and initiated a referral in coordination with R1, family, and the physician. Hospice services began providing additional support, and staff continued to assist R1 with meals, hygiene, repositioning, and supervision as needed.

Interviews with facility staff confirmed that assessments are updated every six months or sooner if a change in condition occurs, and decisions about placement are made based on resident needs, physician input, and family involvement. Records also show that when family raised concerns about R1 needing a higher level of care, the facility offered options such as hospice and provided information on skilled nursing placement, while respecting R1’s wishes. Law enforcement also conducted a welfare check on R1 and found no concerns about neglect or improper care.

Although R1’s health conditions require significant staff assistance, the evidence demonstrates that the facility continues to provide care within its licensed scope, with added support from hospice when appropriate. Therefore, the allegation is found to be UNSUBSTANTIATED .