Complaint Investigation Report

LPA Dolores interviewed a staff member (S1) and it was mentioned that when they we redoing the assessment for R1, RP didn’t allow the staff to check R1s skin. RP told there’s no pressure injury and R1 has redness on the bottom but it’s okay. Upon moving in, the Health Services Director (HSD) wasn’t here. They weren't able to do the skin check upon move in day. It was reported later that there was a tiny opening of .5 cm. HSD checked it and reported it to RP, doctor, and requested home health when they found out there was an opening. There is a PRN cream that needs to be applied. Normal procedure is to do a skin check prior to move in but RP was saying no need to because R1 doesn’t have any issues. That’s the only one that they didn’t do the skin check for. Another staff member, S5, mentioned that R1 has some type of pressure injury and it was not staged. During the pre-assessment there was redness but didn’t check R1s skin. Family didn’t let them check the skin.

LPA Donato was able to interview the Home Health Nurse and it was confirmed that the pressure injury was at stage two.

Based on records review, a charting report showed that on 12/16/2023 input by S6 at 9:30PM that R1 had a blister on left heel and Tylenol was given for pain and discomfort.

Regarding the allegation of staff did not administer resident's medication, RP stated that R1 has butt paste to prevent R1 from getting pressure sores and the staff haven’t been putting it on.

LPA Donato reviewed the Medication Administration Records (MAR) of R1, and it shows that the cream that was prescribed as needed (PRN) and had a direction of being applied topically each bowel movement/diaper change was not done regularly. MAR from October 19-31 2023 showed the cream was only applied for seven random days. MAR from November 2023 also showed cream being applied three to four random days.