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32 | In regards to the allegation: Resident developed multiple pressure injuries while in care, the department investigation consisted of interviews with Staff #1 to Staff #8, review of Resident #1's medical records and facility file (Service plan, physician's order, Home Health records), Resident #1 passed away on 06/14/19, therefore, Resident #1 was not interviewed. Investigation Branch did not interview Administrator but interviewed family member and Residents #4, #7, #11, #12 and #13.
Investigation revealed that Resident #1 was admitted to home health for wound care on 04/18/19. Per treatment records dated 05/06/19 through 05/18/19, indicated Resident #1 was being treated by home health for a Stage II wound on Coccyx, Stage I wound on the left heel and a Stage 1 wound on the right heel. On 05/20/19, Resident #1 was sent to the hospital for treatment due to the Stage II pressure ulcer on the Coccyx getting worse. During the time Resident #1 was in the facility, the Resident was receiving wound care and there is no evidence to support that the facility contributed to Resident#1 developing wounds due to neglect.
In regards to the allegation: Staff failed to address resident's hygiene needs. Interviews with Residents indicate their hygiene needs are met which consist of assistance with bathing, oral/dental care, transferring, incontinence care and dressing. Interview with caregiving Staff also indicate that hygiene assistance is provided based the Residents service plan.
In regards to the allegation: Staff left resident in soiled diaper for extended period of time. Interviews with Resident requiring incontinence care reveal that they are assisted with diaper changes at least 3 to 4 times per shift and had not been left in soiled diapers for an extended period of time. Interviews with caregiving Staff also indicate incontinence care is provided on a sufficient and timely manner.
In regards to the allegation: Staff failed to ensure resident had adequate food intake. A toured of the facility kitchen revealed that there is sufficient supply of perishable and non-perishable foods. Interviews with Resident indicate that facility is providing 3 meals a day. Resident with feeding needs are receiving the proper assistance. Interviews with caregiving Staff indicate that Residents are provided 3 meals a day and Residents with feeding needs are assisted.
Based on the department's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.
Exit interview conducted with Roger Endert and a copy of this report provided. |