Complaint Investigation Report

Facility staff did not properly care for resident's pressure sore - UNSUBSTANTIATED

LPA requested and received medical records from the local hospital that provides care for R1. There was no mention of R1 having pressure injuries in the responsive records. LPA did receive a “Quick Notes” document that was written by R1’s physician dated 6/29/2022 which states that R1 no longer had a wound on the end of the left great toe, the skin is Intact, no new wounds were seen, wound healed.

5 of 5 staff stated they had been trained on how to care for pressure injuries.

Administrator stated in regard to the spot on R1's toe the home health nurse said there was nothing she needed to do with it. The facility coordinated with the home health nurse who suggested that it should be monitored, the family was OK with this decision.

It was determined that R1 did have a abcess on their toe and per R1’s physician the wound had healed. Staff have been trained on how to properly care for pressure injuries should a resident have a pressure injury. This allegation is unsubstantiated.

Facility staff do not properly assist residents with oxygen - UNSUBSTANTIATED

It was alleged that facility staff do not properly assist residents with oxygen.

R1’s Care Plan notes that R1 needs assistance overseeing R1’s care with oxygen. Resident is on oxygen at 2 liters continuously. Resident is independent in changing from their room concentrator to O2 tanks as needed. Staff will assist with filling humidifier bottle and change of tubing monthly. Ensure resident is using their portable oxygen tank for all meals. Resident is to dial the valve to CF2 and 0 when they are hooked up to their portable tank. Resident is now on continuous oxygen at 2L min via nasal cannula. Resident is to utilize the portable oxygen tank anytime they are outside of their room.