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32 | Per hospital medical documentation “examination of extremities reveal marked skin disruption on both legs with a yellowish crusting and excoriation and redness of both legs from the thighs to the feet,” and R1 had “some minor ulceration, including a larger ulcer on the right lateral ankle and some skin tear on the inner thigh. Still no deep wounds.” LPA also reviewed R1’s physician report dated 1/22/19 which states R1 has a history of skin condition/breakdown.
Interviews were conducted with RP, two witnesses, and facility staff regarding allegation resident was left in a soiled diaper for a long period of time. RP stated R1 had been soiled for a long period of time because their shirt was “soiled in urine." Two out of two witnesses reported that R1 has a catheter. W1 stated they did not know if R1 had been left in a soiled diaper for a long period of time but said R1 has an order for their catheter to be changed every 2 weeks which “isn't standard practice. Normally catheters are changed every 4 weeks to prevent clogging." W2 stated R1’s diaper is “only for bowel movements” and said the tubing associated with R1’s catheter was leaking and “that was the problem.” Staff 1 (S1) also stated R1’s catheter had been leaking. S1 stated an incontinence log is not kept however they “always check,” if resident’s diaper is not soiled then it is not changed. Resident 2 (R2) was asked if they are assisted with activities of daily living and could not corroborate the allegation.
Interviews were conducted with Reporting Party (RP), two witnesses, and facility staff regarding allegation staff not repositioning resident. All parties interviewed stated R1 is able to make their needs known. Per RP, R1 stated they are not being repositioned. One out of two witnesses stated R1 had told them they are being repositioned. S1 stated R1 is alert and does not like to be repositioned. Per S1, R1 “always wants to be comfortable.” LPA conducted an interview with R1, who could not corroborate allegation resident sustained injuries while in care. Furthermore, R1 stated they are assisted with activities of daily living and stated they “don’t need” to be repositioned.
Due to conflicting information received during interviews conducted and after a review of R1’s files, and hospital medical records, LPA is unable to determine if Resident sustained injuries while in care, if Resident was left in a soiled diaper for a long period of time, or if Staff did not reposition resident. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore at this time the above allegations are unsubstantiated.
(Cont. LIC9099-C) |