complaint·July 27, 2023

also reveals that R1 is repositioned every two hours. Review of R1's records reveal that R1 is receiving hospice care, and only indicates a stage II at the coccyx, being treated by hospice and facility staff. No indication on file that R1 has anything greater than a stage II injury. Also observed during review of R1's records is confirmation that staff has been changing R1's diaper and repositioning R1 every two hours. No indication that the injury has progressed. Moreover, R1's medical assessment and appraisals does not indicate a history of any skin condition or breakdowns. Based on the information obtained, there was insufficient evidence to prove that R1 developed a pressure injury due to staff neglect in not repositioning R1. Therefore, the allegation is deemed Unsubstantiated at this time. Facility staff failed to monitor resident's water and food intake resulting in hospitalization: In regards to the allegation, it was reported that R1 was taken to the hospital, on or about 07/12/23 for a high fever and possible UTI. It's alleged that R1 had not been fed enough to keep their weight up, was dehydrated, and had a pressure injury. Interview with four (4) of four (4) staff reveal that R1 was sent to the hospital for weakness and loss of appetite. Copy of the Incident Report was obtained to confirm that R1 was sent to the hospital, despite hospice orders. Staff stated R1 does have a pressure injury, but it was being monitored by hospice and facility staff, R1 was being repositioned, and the injury wasn't greater than a stage II. Also, at admission, R1 weighed 161, but because R1 was experiencing a loss of appetite, R1 was last weighed at 158 lbs. Review of R1's discharge papers did not indicate an admitting diagnosis of a high fever and UTI. R1 was admitted to the hospital for another diagnosis on or around 07/02/23 and discharged with new orders to treat their infection approximately seven days after. LPA was able to interview R1 who did admit there are times that they had no appetite to eat, despite staff's encouragement to have their meals. R1 gave no indication, nor alleged staff failing to monitor their water and food intake causing them to go to the hospital. Based on the information obtained, there was insufficient evidence to prove that facility staff failed to monitor resident's water and food intake resulting in hospitalization . Therefore, the allegation is deemed Unsubstantiated at this time.