complaint·April 28, 2023

(continued from LIC 9099) From staff interviews on 09/23/22 and 10/14/22, staff mentioned routine observation of R1 about every two hours. Staff #1 (S1) and Staff #2 (S2) did not notice any pressure injuries on R1 prior to 08/05/2022. From review of R1’s hospital records conducted on 01/25/2023 at 10:20 AM, R1 was seen in emergency department (ED) at approximately 8:30 PM on 08/05/2022. And was transferred to the hospital at 12:00 AM on 08/06/2022. Hospital staff observed R1’s pressure injuries, but a wound consultation was not performed until 4:41 PM on 08/08/2022. At that time, it was determined that R1 developed three (3) Unstageable pressure injuries. A review of medical records did not reveal any supporting information to determine that R1 had unstageable pressure injuries at the time of admission to ED. Based on interviews and record review, there is no sufficient information to support the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Resident sustained an unexplained stab wound while in care”, it was alleged that R1 was stabbed in the knee while under facility care. From medical record review, R1 was admitted to the hospital on the night of 08/05/2022 with “multiple penetrating wounds”. From interviews conducted on 09/23/22, 10/14/22, and 10/28/22, no residents or staff witnessed the incident. On the night of 08/05/2022, R1 was observed on the floor of their room with blood on their leg and head. A broken coffee cup was also seen on the ground. R1 did not reveal how the injury happened. Resident #2 (R2) was the roommate of R1, and R2 did not report any previous issues or altercations with R1. R2 initially denied any knowledge of R1’s injury. R2 later stated that R2 hit R1 with the coffee mug but did not disclose further details. R2’s interview was of low credibility due to inconsistencies in R2's statement. From interviews and record review, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Resident was assaulted while in care”, it was alleged that R1 was stabbed by an unknown assailant at the facility. From record review, the facility submitted an incident report after the police investigation. The police report has yet to be released, though it was determined that the stab wounds were self-inflicted. From interviews on 09/23/22 and 10/14/22, staff and residents did not see or hear any altercations leading up to R1’s injury. Staff #2 (S2) stated R1’s roommate R2 was observed lying down and appeared to be asleep when R1 was injured. Based on record review and interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. (continued to LIC 9099-C) (continued from LIC 9099-C) Regarding the allegation “Staff are not providing a safe environment for resident in care”, it was alleged that R1 was unsafe at the facility”. From interviews 09/23/22 and 10/14/22, residents expressed no safety concerns and felt treated well by staff. Staff described their frequent observation of residents about every two hours. Staff had not observed any signs of danger or unsafe situations. R1 and roommate R2 maintained a good relationship. From file review conducted on 01/25/2023 at approximately 10:45 AM, the facility did not have a history which indicated a lack of safety. Based on interviews and file review, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.