Complaint Investigation Report

Outside source also revealed that R1 does have redness on back side but not enough to be considered a pressure injury. Interview with additional outside source did not reveal any information to corroborate that R1 neglect by facility staff has resulted in pressure injury.

It was also alleged that R1 neglect has resulted in multiple R1 falls. Records collected revealed that R1 does have a fall risk. Interview with staff revealed R1 tends to move self-off of bed and onto the floor but does not fall. Records also revealed that R1 is checked-on multiple time throughout the day. Interview with outside medical source also corroborated that R1 tends to have episodes of agitations and puts themselves on the floor. Records and interviews did not reveal R1 has sustained any injuries from these incidents.

Lastly, it was alleged that R1 has been fearful of staff not providing meals to R1. Interview with staff revealed R1 receives three meals per day. Interview with outside source established that outside source has not been informed of R1 not receiving meals. Records reviewed revealed that R1 has received multiple meals on today’s visit, May 29, 2024.

Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.