Complaint Investigation Report

February 25, 2021, with additional wounds (staging not noted) were observed on or around March 07, 2021. On or around March 1, 2021 one wound was reported to have progressed to a stage 4 on a Physician's Orders report.

The resident was later hospitalized on March 12, 2021; records show R1 was observed to have multiple injuries; including a pressure ulcer of sacral region, stage 4.

Facility staff were interviewed and reported wounds were not observed on R1, however staff reported R1 was rotated every two hours. The Administrator stated R1 needed “aggressive wound care” but that home health was unwilling to come in regularly. Administrator stated home health told them “not to touch the wound.”

Based on the investigation, the allegation that staff neglect resulted in resident developing pressure injuries could not be corroborated. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. 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 the alleged violation occurred.

This report was reviewed with Madahar and a copy was provided.