complaint·April 14, 2022

On 4/30/2021, R1 was admitted to memory care unit from assisted living. An initial health assessment was completed on 5/26/2021 and no indication of any rashes during skin assessment. On 8/6/2021, S2 observed a wound on bottom of right foot, and notified R1’s responsible party and primary care physician. Wound care was initiated by Pine Park Health (PPH) and ProHealth Home Health (PHHH) on 8/19/2022 and 8/20/22; respectively. Staff were instructed to reposition R1 every 2 to 3 hours and offload pressure. Based on interviews with staff, staff reported that R1 was being repositioned as they were instructed. The Department was unable to provide or disprove there was neglect by the facility. Although, R1 sustained multiple wounds while at the facility, R1 was receiving wound care by PPH and PHHH. W1 stated home health was aware R1 sustained multiple pressure injury due to R1’s bed bound status and there were no concerns of staff being neglectful. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, and a copy of this report provided.