Complaint·June 7, 2022

The investigation revealed the following: Regarding the allegation: Staff did not tell authorized representative of change in resident's condition. “ It’s being alleged that the facility staff did not notify reporting party that a resident had a pressure injury.” During interviews with residents: 0 out of 7 could not confirm this allegation to be true. on 05/16/2022 at 11:20am R1 states, “I’m not sure if my wound was reported.” On 06/072022 at 10:28am R2 states, “if it’s serious enough they will call the paramedics and then my daughter. It has happened about 3 or 4 times. They are right on top of it. I can’t complain about my care at all here.” On 06/07/2022 at 10:42am R4 states, “I don’t know how many times I’ve gone to the hospital, but they have told my family every time.” On 06/07/2022 at 10:55 am R6 states, “yes they notify my family if there is a change in my health condition.” On 06/07/2022 at 11:01am R7 states, “yes they communicate very well here.” During interviews with staff, 0 out of 6 could not confirm this allegation to be true. On 05/16/2022 at 11:12am S1 states, “we always communicate if there is a change in conditions of a resident.” On 06/07/2022 at 11:09am S2 states, “yes that’s my job and vice versa. The staff report to me and I follow up. For R1 it wasn’t a pressure injury or sore. It was like a scratch that would come and go.” On 06/07/2022 at 11:26am S5 states, “yes of course. First, we call our supervisor and then the family. The supervisor calls the families. R1’s family knew because S2 made contact.” On 06/07/2022 at 11:31am S6 states, “I’ve worked here for 2 months and from what I have seen they do report changes to the families.” Regarding the allegation: Resident received a pressure injury while in care. “ It’s being alleged that a resident developed a pressure injury while in care.” During interviews with residents: 6 out of 7 could not confirm this allegation to be true. 1 out of 7 confirmed the allegation to be true. On 05/16/2022 at 11:20am R1 states. “I got this wound because they were leaving me wet at night.” On 06/07/2022 R2-7 all state not knowing of any residents having or had a pressure injury. They also stated not having any pressure injuries themselves.” During interviews with staff, 0 out of 6 could confirm this allegation to be true. On 05/16/2022 at 11:12am S1 states, “we didn’t know about an open sore until R1’s relative reported it. The staff reported not seeing any open sores.” On 06/07/2022 at 11:09am S2 states, “for R1 it wasn’t a pressure injury or sore. It was like a scratch that would come and go. The staff mention that it was a scratch. It was not something that was alarming.” On 06/07/2022 at 11:17a S4 states, “I gave her a shower and saw that she had a scratch. I asked Cont on 9099C her what was it and she told me I scratched my back.” On 06/07/2022 at 11:26am S5 states, “I don’t know if she had pressure injuries. It did not look to be so based on the ones I’ve seen in the past.” On 06/07/2022 at 11:31am S6 states, “during the appointment the doctor told the relative it was nothing to worry about and was going to order home health as a precaution.” Regarding the allegation: Resident is being left in soiled diapers. “ It’s being alleged that a resident was being left in soiled diapers.” During interviews with residents: 6 out of 7 could not confirm this allegation to be true. 1 out of 7 confirmed the allegation to be true. On 05/16/2022 at 11:20am R1 states, “they were leaving me wet at night. The staff used to come check on me, but they stopped. When I’m wet, I call them and even more now because of the wound. They answer now but they were leaving me wet before.” On 06/072022 at 10:28am R2 states, “I don’t know anyone that has had those types of issues.” On 06/07/2022 at 10:35 R3 states, “the only person that I know has diapers is my roommate. They never complain.” On 06/07/2022 at 10:51am R5 states “they pretty much change me when I’m wet. I don’t know anyone that is left wet.” On 06/07/2022 at 10:55 am R6 states, “no, they don’t leave me wet. They take care of me very well.” During interviews with staff, 0 out of 6 could confirm this allegation to be true. On 05/16/2022 at 11:12am S1 denied the allegation. On 06/07/2022 at 11:09am S2 states, “with R1 they are very alert, so they called. So, not that I’m aware of. I personally monitor the night shift and R1 was being checked.” On 06/07/2022 at 11:17a S4 states, “we always changed R1’s diapers. They called and we would come.” On 06/07/2022 at 11:31am S6 states “I don’t know about that. As far as I know R1 calls regularly to get their diaper changed.” Regarding the allegation: Insufficient staffing to meet resident’s needs . “It’s being alleged that there are not enough staff to help walk a resident and not enough staff at night to change the resident.” During interviews with residents: 4 out of 7 could not confirm this allegation to be true. 3 out of 7 confirmed the allegation to be true. On 05/16/2022 at 11:20am R1 states, “they are understaffed here.” On 06/072022 at 10:28am R2 states, “sometimes it seems a little short but whenever you need someone to help, they help. You might have to wait a few minutes, but they come. On 06/07/2022 at 11:01am R7 states, “they can use more male staff. We are much heavier for the ladies in case one of us falls.” On 06/07/2022 at 10:35am R3 states, “I think there is enough staff. I think so.” On 06/07/2022 at 10:42am R4 states, “yes, there is enough staff.” Cont. on 9099C During interviews with staff, 0 out of 6 could confirm this allegation to be true. On 05/16/2022 at 11:12am S1 states, “We have the same staffing numbers we had when I had more residents. Plus, we use agency staff. There are three people on at night. During the day, there are 5 on.” On 06/07/2022 at 11:09am S2 states, “yes, we have enough staff. In the case of R1, they were beginning to require more support.” On 06/07/2022 at 11:26am S5 states, “we have enough staff. Right now, there is 5 or 6 on shift. The night shift is fine.” On 06/07/2022, LPA reviewed the visit summary from R1’s doctors visit which indicated home health was order due to R1’s relative observation of an unspecified, unstageable pressure sore with minimal skin breakdown. Physician staged pressure injury as a 2 in order to start wound care to avoid the wound from worsening. On 05/16/2022 at 1:37pm LPA interviewed home health (W1) who states, “it was a bed sore, but it was only a stage 2 and its closed now. It was a tiny wound. We only provided services twice. Once on 4/11/2022 when the case was open and on 04/14/2022. It was less than one millimeter. The wound was 0.5 CM and 0.1 centimeters. LPA reviewed a copy of staffing schedule for May 2022 which indicates sufficient staffing. LPA reviewed an invoice for agency staffing. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. 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. An exit interview was conducted, and a copy of the report was given.