Complaint Investigation Report

R1’s Visual/Bedside Individual Service Plan Report is dated 03/29/2021. The Dressing section states “Stockings: Compression applied – REMIND HIM to apply” and “Stockings: Compression removed – REMIND HIM to remove.”

R1’s Physician made an order to the facility for R1 to have compression stockings for both feet on 01/27/2021.

R1’s Intervention Schedule indicates that the first entry for reminding R1 to apply and remove R1’s compression stockings started on 01/27/2021. The Intervention Schedule has an “X” on the following days for the intervention of staff reminding R1 to remove the compression stocking: 01/31/2021, 02/28/2021, and 03/31/2021. The rest of the days of the month from January to March 2021 indicate that staff reminded R1 to apply and remove R1’s compression stocking.

During interview, staff S1 stated that an “X” may indicate that either staff missed the intervention, or the resident refused the intervention.

Witness 1 (W1) provided photographs to LPA Marrufo of what W1 says is R1’s ankle showing markings of the fastener from the compression stockings. R1’s ankle appears narrower where the fastener markings are visible.

LPA Marrufo reviewed R1’s resident record and did not find any document from R1's physician holding facility staff responsible for assisting R1 with the use of the compression stockings.

R1’s resident record contains a note from R1’s Primary Care Physician (PCP) from 08/16/2021 stating that R1 is refusing to apply the compression stocking.