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32 | Also, copies of the following documents were obtained and reviewed in reference to C1;
• Client Information Sheet • Admission Agreement • Agreements and Consent for Medical Treatment
• Personal Rights • Individual Program Plan (IPP) • Behavior Consultant Notes • Special Incident Reports
• Hospital/Medical Reports • Facility Client Notes • Body Assessment Sheet • Staff Roster • Client Roster
The investigation revealed the following;
Allegations: Resident sustained unexplained injuries while in care and Staff did not seek medical attention for resident in a timely manner. The details of these allegations state that C1 was placed on a CPI hold which caused injury to C1’s toes (both) and fingernails and staff didn’t seek medical care for C1 until prompted by the family of C1.
Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with these allegations. During the interview of C1, C1 admitted to having ongoing issues with his nails as a result of cutting his nails too short, picking at them and bumping his toes. C1 stated that “maybe the bloody toenails were as a result of staff stepping on my toes during the CPI hold but I’m not sure.” The Administrator and staff also confirmed that C1 had ongoing issues with his nails as a result of cutting his nails too short, picking at them and bumping his toes.
According to the Client Notes documented by staff, on the morning of 11/5/21, the toenails of C1 were observed to be bloody. Later that same afternoon, staff took C1 to the hospital (Emanate Health) for a check-up. According to the hospital report, C1 was diagnosed with Cellulitis of great toe of left foot and Cellulitis of great toe of right foot and recommended to follow up with primary care provider for reassessment. On 11/17/21, C1 had a tele-health visit with his primary care physician (PCP) at ReNovi Medicine. The PCP noted on the report “Cellulitis bilat hallux toes, thinks patient cut nail too short and bumped the toes.” On 11/18/21, C1 saw his PCP (in-person) and the PCP gave a referral for a Podiatrist stating “bilat foot pain and ingrown toenails”. On 12/6/21, C1 was seen by the Podiatrist and diagnosed with “severe ingrown toenail”. On 12/8/21, C1 had a follow up tele-health visit with his PCP at which time the PCP noted “Continue to monitor closely” and recommended for outpatient surgery if no improvement. On 1/21/22, C1 had a follow up visit with the Podiatrist (diagnosed: Rt & Lt hallux cellulitis, recommended surgery). On 1/26/22, C1 had surgery on both toenails (Lt and Rt hallux toenails). The SGPRC conducted an investigation and the following recommendations were made; (please see LIC 9099C for additional information) |