complaint·January 11, 2022

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff neglect resulting in resident developing pressure injuries while in care. It is alleged that resident developed pressure injuries while in facilities care due to staff neglect. According to facility records R1 was on home health and there was a wound care order from doctor as well as a wound care plan given by the home health agency to treat the pressure injuries R1 gained while in skilled nursing care. R1 was sent to the hospital on 8/24/2020 and was admitted from the hospital to a skilled nursing facility from 8/30/2020 until 10/20/2020. In case notes from skilled nursing facility it was noted that resident had a pressure injury, but it was not the same one for which they were previously receiving home health. Upon return to facility on 10/20/2020 facility conducted a body check and contacted R1’s doctor regarding pressure injury. On 10/21/2020 Home health services ordered by physician, on the same day home health received the order and treated pressure injury. A few days later, on 10/24/2020 R1 was sent to the hospital. They were released on 10/30/2020 to skilled nursing care and did not return to facility before they were hospitalized again on 11/17/2020 which is when five pressure injuries were noted by hospital staff. LPA Cifuentes interviewed residents 2 - Residents 12 (R2-R12). R1 was not available for interview by LPA but it was noted that they did not feel there was any neglect on the facilities behalf. All residents interviewed stated they did not have any pressure injuries. When asked if they felt staff took good care of them, 10 out of the 11 interviewed stated they felt staff took good care of them, with one stating they needed no assistance. Based on information gathered and service records reviewed, the Department did not find sufficient evidence to support the allegation mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated . Exit interview conducted, and a copy of the report was given to Assistant Administrator Veronica Gomez.