Complaint Investigation Report

An assessment was done and no apparent injury was noted. R1 denied any pain or discomfort. Staff notified R1’s spouse and R1’s Primary Care Physician (PCP) visited R1 at 10:00 AM. PCP noted R1 was able to move all extremities at baseline and R1 continues to deny pain or discomfort.

The Transfer/Discharge Report dated 04/23/2020 states that R1’s diagnoses include fracture of lower end of right fibula and muscle weakening and atrophy on multiple sites.

R1’s Appraisal/Needs and Services Plan states that R1 needs two staff to assist R1 with transferring. This assessment was completed on 05/05/2018.

During interview, R1 stated that two staff assisted R1 during transfer on 03/22/2020. R1 stated to not remember who the two staff were. R1 stated to have confidence in the abilities of facility staff.

During interview, staff S1 stated to not be able to recall who were the two staff who assisted R1’s transfer on 03/22/2020. S1 is the staff who wrote the Incident Report.

R1’s Physician’s Report states R1 is not able to care for R1’s own toileting needs.

R1’s Appraisal/Needs and Services Plan states R1 needs to be provided with frequent assistance to change R1’s incontinent product.

R1’s Progress Notes from 02/13/2020 notes R1 continues to wear condom catheter and a new bag was put in place. In-service done with care team for proper instructions.

The facility Training Participation Log states on 03/18/2020, a training on Condom Catheter and Urostomy was provided to staff.

See LIC9099-C for more information. Page 2 of 3.