Complaint·December 2, 2021

Records review revealed, R1 has a history of skin integrity. It was discovered that R1 was ambulatory, independent, and was able to perform most ADLs. LPA was unable to find any documentation related to any pressure injury. Specifically, Home Health Nurse documentation revealed that no wound could be found 5 days after hospital discharge. Staff interviews conducted revealed that R1 had a history of dry skin and rash which was being treated by prescription ointment. Staff interviews did not reveal any history of wounds or issues with skin integrity due to neglect. LPA interviewed R1's POA who acknowledged that R1 had a history of skin issues and skin tears due to skin fragility. LPA additionally interviewed R1's assigned Home Health Nurse who acknowledged that R1 was mostly independent of ADLs, active, and never observed any pressure injuries. Due to the information above, LPA finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Executive Director, copy of report was provided via email. Appeal rights were printed and given with the report.