Complaint Investigation Report

Additional records revealed that R1 had sustained falls at their residence prior to hospice and facility admission. Records showed that R1 had diagnosis’ that would place them at risk for injuries.

It was alleged that resident #1 (R1) sustained a stage 4 pressure injury due to staff being neglectful, not repositioning the resident and kept changing the bandage. Interviews with staff said they would reposition the resident, but the resident would never stay in the positions that either staff or their care agency would place R1 in. According to Administrator Rafols, the care agency had informed them, on 05/17/2021, that R1 was being provided wound care. The Administrator said that they provided wound care daily for R1. The care agency had instructed staff to dry, clean and reposition R1 every two hours which staff adhered to. According to Administrator Rafols, at night staff would also conduct their checks every two hours. Interview was conducted with an outside source who confirmed that the facility personnel followed instructions provided by R1s care agency. Per the outside source, R1 was at risk for skin breakdown from the beginning due to poor intake of food, lack of mobility, age, underlining medical conditions and repositioning self-back to the same position after being repositioned to an alternate position by facility staff and R1’s caring agency. This continued when R1 obtained the injury which did not allow the injury to breathe. Staff kept the bandage dry and clean as indicated by the care agency. According to the outside source, there was no evidence to prove that personnel were neglectful while caring for R1 or any other residents. Based on the information obtained there is insufficient evidence to support the allegation.

It was alleged that staff #1 (S1) handled R1 in a rough manner pushing R1 against a railing. Interview with S1 said that they started to volunteer on 6/03/2021. According to S1, they denied hurting R1. R1 left 06/03/2021. S1 said that they and S2 would care for R1. According to Licensee, there was never a time where a family disclosed that a caregiver was rough with a resident nor a resident obtaining an injury due to staff. Interview with an outside source said that they had no issues with the staff at the facility. They were continuously there assisting R1 and saw that the staff were accommodating with the care they provided to them. There were no records to show that there were any incidents reported to the Regional Office by the facility or a third-party agency to indicate that R1 was being mishandled. Based on the information obtained, there is insufficient evidence to support the allegation.