Complaint Investigation Report

On 11/30/23, the Department received allegations that the facility did not seek timely medical attention and neglected care and supervision for a resident herein referred to as R1. R1 had an untreated wound which was not reported to licensing office.

On 12/08/23, the Department conducted an initial investigation and interviewed staff (S1). S1 stated that R1 had an unwitnessed fall sustaining an injury to the left elbow with a superficial skin tear on 11/21/23.

S1 stated that R1s fall was reported to responsible party (RP) and medical doctor (MD). S1 stated that R1’s wound was not serious, was cleaned and a band aid was applied. Since it was not serious, the facility did not report R1’s wound to licensing.

On 11/27/23, R1’s responsible party moved R1 to another Residential Care Facility for the Elderly (RCFE). It was reported that during R1’s assessment the facility did not inform the prospective facility that R1 sustained a wound on elbow aside from other minor abrasion on his/her knee during an assessment.

Based on review of Nurse’s notes dated 11/21/23, it was noted that R1 reported to the Wellness Nurse at 9AM that he/she fell during the night but does not remember how it happened. R1 sustained a left skin tear on left arm and some redness on left knee. R1s wound was cleaned and treated, and dressing applied. R1’s primary care physician (PCP) was notified on the same day [11/21/23] with a reply date of 11/24/23 which states, “can give Tylenol 500mg every 6 hours … and please wash skin tear clean and put band aid over.”

On 11/28/2023, R1’s wound was reported to his/her PCP. PCP stated the facility staff did not describe the severity of the wound and how bad it was when he/she received a note from the facility On 11/21/23, the note states that R1 had a skin tear on left arm and some redness on the left knee. PCP prescribed R1 some antibiotics and will require the services of a home Health aide to come and assist with the wound care for R1 at his/her new placement.

Based on record review such as R1’s physician’s report dated 5/23/23, R1 has diagnosis of neurocognitive disorder.