complaint·October 26, 2023

Investigation revealed the following: In regards to the allegations “resident sustained pressure injuries while in care” and “resident did not have care plan for pressure injuries”. It is alleged that Resident #1 (R1) did not have a care plan for pressure injuries and therefore sustained pressure injuries while in care at the facility. This allegation was investigated by Investigator Brunelli with the Investigations Branch. R1 was diagnosed with Cerebral Palsy, history of epilepsy, and later non-ambulatory with contractures of arms and legs. R1 was admitted to facility and transferred to hospitals for wound care treatments from dates 2/18/21 – 7/20/21. Wounds would be treated and monitored at facility by home health. Based on interview with both hospitals Wound Care Ostomy Nurses and Home Health Care Nurses treating R1, all revealed the pressure injuries were not infected, looked healthy, small, and superficial and there were no concerns for abuse or neglect based on the pressure injuries. Based off of two hospital record reviews for R1, facility file review, interviews with both hospitals treating wound care nurses, interviews with family, interviews with treating home health care nurse, and previous medical history it was determined that it does not appear the care provider delayed in transferring R1 to a hospital for Skilled Nursing Facility (SNF) for wound treatment. Based off of record review and interviews with treating home health care nurse there was a wound care plan for R1 with a written order from the facility doctor with recommendations and a progress plan. Based on statements and interviews conducted with staff and family, review of R1 files and medical records, there was not enough supportive evidence to concur with the reported allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Assistant Administrator Martha Rosas and Administrator Pamela Ogot.