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32 | Regarding allegation: Staff neglect resulted in a resident sustaining multiple pressure injuries.
It is alleged that staff did not provide a resident with adequate care, which led to the resident developing several pressure injuries. The investigation consisted of interviews with staff, residents, and review of R1 facility files including discharge hospital records and hospice care plan. The investigation reveals the following: R1 was admitted to the facility on 08/20/2025 with no wounds and R1 was admitted to Hospice on 08/21/2025. Review of R1s facility records revealed that R1 had a hospital visit on 12/05/2026, and there are no documents indicating that R1 had developed a pressure injury on 12/05/2026. On 12/16/25, R1s hospice records revealed that R1’s hospice attending nurse documented it was observed that R1 had a new onset Stage II to Upper Coccyx. Hospice Nurse provided staff with instructions to staff to care for R1’s wounds, which included cleaning, medication, and re-positioning. On 12/21/2025, R1 was sent to the hospital for shortness of breath. R1’s hospital discharge records dated 12/23/26 indicated that R1 had developed lower back unstageable pressure injury to lower back. R1s Facility Medication Administration Record (MARs) for the month of December 2025 revealed that the facility implemented and followed R1s hospice wound care plan beginning December 16, 2025, which included staff repositioning R1 every two (2) hours, cleaning wound, and applying medication. The facility MARs indicated that staff provided followed R1’s wound care until R1 was sent to the hospital on 12/20/2025. Interview with residents revealed that six (6) out of eight (8) residents were not aware of any resident bedbound to have developed any wounds from being in bed or on wheelchair. Interviews with staff revealed that six (6) out of six (6) staff were not aware of the above allegation. Staff indicated that R1 spent most of the day in the wheelchair. Staff stated that staff assisted R1 with repositioning in wheelchair and at bed when R1 was awake. Staff assisted R1 with transferring from bed to wheelchair whenever R1 requested transfer assistance. Based upon the investigation, resident and staff interviews, document review, and LPA observations, there is no evidence to support the allegation that facility’s neglect caused R1 developing pressure injuries.
Regarding allegation: Staff did not prevent a resident from physically assaulting other residents.
It is alleged that facility staff did not take action to prevent a resident assaulting another resident in care. Investigation consisted of interviews with staff, residents, and review of resident #1 (R1) and resident #7 (R7) facility files, including admission agreement and physician’s report. The investigation revealed the following: Interviews with six (6) out eight (8) residents revealed that residents denied being assaulted at facility and residents denied knowing of other residents being assaulted at the facility.
(Report continues on page LIC-9099C...) |