complaint·April 1, 2024

R1 was discharged from the hospital and returned to the facility on January 6, 2024 by R1’s family. Per R1’s discharge paperwork, R1 showed signs of delirium, but no hospital documentation indicated that R1 had skin breakdown. On January 7, 2024, R1 began home health services with Excell Home Health, and R1 was assessed by the nurse, who also did not report or observe any skin issues. On January 14, 2024, facility staff observed wounds on R1’s sacrum and buttocks while changing R1, and staff notified the home health nurse who cleaned and dressed R1’s wound the same day. On January 15, 2024, when R1 was being changed, staff observed that R1’s wounds had worsened, therefore, sent R1 out to the hospital to obtain further medical evaluation. An interview was conducted with R1’s family who stated that the facility is not to blame regarding R1’s condition and expressed satisfaction regarding the facility care given to R1. Based on interviews which were conducted, review of documents obtained, and observations, there is insufficient evidence to ascertain if the allegation occurred as reported, therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with BOM Chairez. A copy of this report was provided and explained.