Complaint Investigation Report

Regarding the allegation, neglect resulting in resident sustaining pressure injuries, it was reported that Resident (R1) sustained pressure injuries as a result of the facilities’ neglect. A records review revealed a doctor’s note dated 5/22/2023 stating that R1 had stage 2 pressure injuries, and it was ordered that R1 was to receive wound care twice a week and be repositioned every two hours. Records review showed that hospice nurses visited R1 and provided wound care. Interview with outside source (OS1) revealed that R1 was provided wound care by hospice nurse and was repositioned by private caregiver. Interviews with facility staff revealed that staff reposition residents who are at risk of pressure injuries every two hours and reported no concerns for resident neglect.

Regarding the allegation, neglect resulting in resident sustaining an infection in mouth, it was reported that R2 sustained a rash in the mouth due to facility neglect. Records review revealed that R2 was prescribed medication Nystatin to treat infection in mouth and was seen by a Home Health agency. Records review show that there was a delay in getting the signed doctor’s order for the Nystatin due to the doctor’s office not sending over the order. Records review showed the facility advocating for the resident by calling the doctor’s office and requesting to follow up on doctor’s order. Interviews with facility staff revealed that staff had no concern for facility neglecting residents and reported that all residents are cared for. Interviews with residents revealed no concerns. Interview with outside source (OS2) revealed that staff reported the infection in R2’s mouth immediately and medical attention was sought out.

Regarding the allegation, staff did not seek medical attention in a timely manner, it was reported that residents have made complaints such as being in pain and staff do nothing. Interviews with facility staff revealed no concern for residents not receiving timely medical attention. Interviews with residents revealed no concern for delay in seeking medical attention. Interview with outside source (OS2) revealed no concern for residents not receiving timely medical attention.

Regarding the allegation, residents are not treated with dignity, it was reported that residents are not allowed to go outside. LPA conducted a walk through of facility and observed several doors that lead to outside area to be unlocked and accessible to residents. Interviews with staff revealed that residents are allowed to go outside, and facility has ample outside area for residents to utilize. Interviews with residents revealed that there is an outside area for residents to go to that is always available. Interview with outside source (OS1) revealed that facility has an outside area, and residents are able to go to outside area. Continued on an LIC 9099C.