complaint·December 8, 2021

Allegation/Personal Rights: Resident sustained multiple pressure injuries while in care. The investigation revealed that on 02/08/21, R-1 was initially diagnosed in the Emergency Department with a stage III pressure injuries on R-1’s left and right side buttocks upon admission to the hospital. Per investigation, that same day of admission, a wound care nurse reassessed the wounds and diagnosed them as Stage II pressure injuries. Per facility staff interviews, on 01/27/2021, R-1 was sent to the hospital for generalized weakness with no pressure injuries noted. R-1 was discharged to a skilled nursing facility (on 01/30/21) up until R-1 was taken back to the hospital on 02/08/21. During the 02/08/21 hospital visit, R-1 was diagnosed with pressure injuries (as noted above). R-1 was treated and discharged back to the skilled nursing facility on 02/11/2021. R-1 did not return to this facility since 01/27/21 hospital admission. Medical records review from the skilled nursing facility did not identify any stage III pressure injuries upon R-1’s admission (01/30/21) to the skilled nursing facility. Interviews conducted and documentation reviewed do not corroborate this allegation. Allegation/Personal Rights: Resident was found unresponsive at the facility due to a health condition. On 02/08/21, R-1 (while residing at the skilled nursing facility), was taken to the hospital. Per facility staff interviews, on 01/27/2021, R-1 was sent to the hospital for generalized weakness. R-1 was discharged to a skilled nursing facility (on 01/30/21) up until R-1 was taken back to the hospital on 02/08/21. R-1 was treated and discharged back to the skilled nursing facility on 02/11/2021. R-1 did not return to this facility since 01/27/21 hospital admission. Interviews conducted and documentation reviewed do not corroborate this allegation. Based on the information gathered, the allegations of “Resident sustained multiple pressure injuries while in care” and “Resident was found unresponsive at the facility due to a health condition” are unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. Therefore, the complaint allegation is being dismissed. An exit interview was conducted and a copy of this report and Appeal Rights were provided to Facility Administrator.