complaint·March 27, 2024

The investigation revealed the following: Regarding the allegation: Resident sustained pressure injuries while in care. It’s being alleged a resident had a stage 2 bed sore. During interviews, LPA interviewed two (2) out of two (2) staff. S1 confirmed R1 came to the facility with a stage 2 bed sore which was being treated via hospice services. S1 denied any additional wound development. During a record review, a nursing summary from Bristol Hospice dated 02/17/2022 indicated R1 was receiving care for a stage 2 bed sore which completely healed. S2 was unable to confirm the allegation due to not knowing R1. R1 was unavailable for an interview due to passing away. Regarding the allegation: Staff mismanaged resident's medication. It’s being alleged R1 is not receiving morphine pain medication for extreme pain. Rather, R1 was given Tylenol. During an interview with S1, they stated R1 never reported being in extreme pain, therefore Morphine was not administered. During a record review, LPA observed that extra strength Tylenol is an approved pro re nata (prn) for R1, making the facility compliant with R1’s Medication Administration Records. Interviews were attempted with all five (5) residents of which one (1) reported no issues with their medication. The other four (4) residents were unable to participate due to their cognitive function. Based on records reviewed and interviews, both above allegations are unsubstantiated. Exit interview conducted and a copy of the report was given.