complaint·August 16, 2022

Medical records showed that prior to admission to the facility, R1 had a fall in R1’s home with ongoing pain. R1 reported sudden onset of bilateral leg weakness where R1 was found with a new T11 fracture. R1 had a custom Thoracic Lumbar Sacral Orthosis (TLSO) brace that R1 was directed to wear any time R1 was not laying in bed. R1’s family member (FM) stated that R1 fell while R1 was living in R1’s home and R1’s vertebrae were shattered and had a surgery. FM stated R1 was given a brace to be worn all day and from rehab, R1 moved to the facility where R1 was seen by Home Health who provided wound care. Social Worker (SW) stated that R1 was admitted to the emergency, and after being seen by the doctor, was determined that R1 was septic due to a stage IV on R1’s lumbar spine. It was also determined that the TLSO brace was pressing on the area causing the pressure injury, and the hospital staff were sure that the pressure injury was caused by the brace. S1 and S2 stated that R1 wore the brace and only removed when sleeping which corroborated with R1’s statement. R1 indicated that the injury was not caused by neglect by staff but by the brace. Residents (R2 and R3) were interviewed who both confirmed that R1 had been wearing the brace which looked uncomfortable but R1 never complained of pain. Based upon records review and interviews, the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis, therefore, the complaint is dismissed. Exit interview conducted and a copy of report provided.