complaint·April 8, 2025

Regarding the allegation: Resident sustained multiple pressure injuries due to lack of care from staff. It is being alleged that resident #1 (R1) sustained multiple pressure injuries (including an unstageable ulcer on their left hip) while in care of the facility. On 01/23/25, at 07:29am, IB Investigator subpoenaed Kaiser Permanente’s, Release of Information (ROI) Unit, for the medical records of R1 but had to resend the subpoena on 01/24/25. The medical records were not received until 02/25/25. According to the medical records, R1 had a “history of unstageable pressure ulcer to right ankle and stage 3 pressure ulcer to left sacrum. On 01/23/25, at 10:51am, IB Investigator subpoenaed the Comcare Home Health main office for medical records of R1. On 02/14/25, multiple emails containing the home health records of R1 were received. According to the records, from November 7, 2024, to January 5, 2025, both home health nurse and facility caregivers confirmed that R1 would regularly move around, after being repositioned, and return to a position that was comfortable for them. The home health nurse advised that facility staff provided adequate supervision as evidence that they would come daily at “random” times and R1 always had a clean diaper, bed pad, and bed linens. Facility staff attributed to R1’s lack of healing to poor circulation of R1 being bed bound. There is not enough evidence to support the allegation that a lack of care caused R1 to develop pressure injuries. Therefore, based on the observation, record review, interviews conducted by the IB Investigator, the allegation is UNSUBSTANTIATED at this time. Exit interview was conducted, no citation(s) were issued for the above allegation(s) and a copy of this report was given to the Medication Technician, Jolene Halog.