Incident investigation·December 3, 2024

12/03/2024 12:55 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with interim administrator Tony Greer. Today’s visit is regarding an incident that occurred on 11/15/2024. It was reported that on 11/15/2024 Resident 1 (R1) stated that Staff 1 (S1) and Staff 2 (S2) were re-positioning them in their wheelchair. Stated S1’s nails dug into the skin of their armpit and caused two open areas. Physician was notified and assessed the areas on 11/19/2024 and diagnosed abscess and prescribed antibiotics. During the course of the investigation, it was learned that R1 did not indicate that they were in pain or discomfort while staff were transferring them. R1 was examined by the physician who diagnosed R1 with an abscess, not an open wound. The resident has completely healed and is doing well. In order to prevent this from happening again the facility had Freedom Home Health come in conduct transfer training for all staff on 11/21/2024. The training consisted of bed, chair, wheelchair transfers and how to assist a resident up from a fall safely. Staff have been reminded that resident safety comes first and fingernails should be kept at an appropriate length to safely provide care. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to with interim administrator Tony Greer.