Complaint Investigation Report

was revealed R1 and R2 had passed away and so interviews could not be conducted. Hospice medical records were obtained for each resident. Records show neither residents were diagnosed with pressure injuries; however, staff were instructed to reposition/turn both residents regularly. R1's medical records indicate red skin noted to their coccyx. Daily notes were reviewed for each resident. Notes did not indicate R1 was or was not repositioned/turned regularly. Resident interviews were conducted though unsuccessful; due to resident cognitive decline, information could not be obtained. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

With regard to the allegation, "Resident sustained stage four pressure injury while in care." it was alleged Resident Three (R3) sustained a stage four (4) pressure injury while in care of the facility. Prior to the completion of the investigation it was revealed R3 had passed away and so an interview could not be conducted. Medical records were obtained; an Interdisciplinary Plan of Care Update/Meeting revealed R3 was receiving hospice services for a stage II pressure injury to their Coccyx. R3's records revealed the resident was hospitalized on November 22, 2019 and diagnosed with a stage III to IV sacral decubitus ulcer prior to discharge. R3's Hospice notes reveal the initial injury was a result of incontinence and poor eating. Therefore, due to a lack of information, 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 that the alleged violations occurred.

An exit interview was conducted with Sanry, in which this report was reviewed and a copy provided.