Complaint Investigation Report

During the investigative process, numerous staff persons were interviewed. Various documents were obtained and reviewed to include medical charting, death certificate, hospital records, photos of pressure injuries, incident reports, Individual Program Plan, Admissions Agreement, and Physician’s Report.

During the interview process it was reported that the resident (Resident 1) was taken to the health center weekly for three weeks prior to being admitted to the hospital for evaluation of pressure injuries. It was stated that the resident was taken to the doctor immediately following pressure injuries being first observed and that the doctor’s orders were being followed. Documentary evidence obtained supports staff statements that the resident was being changed frequently to prevent further advancement of wounds. There was not a preponderance of evidence to show that staff were negligent in seeking medical treatment for the resident’s wounds or following doctor’s orders in wound care.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated .