complaint·March 16, 2023

According to allegations, facility staff were only changing resident’s incontinence undergarment twice per day, resulting in pressure injuries but no specific time frame was provided. According to records collected, R1 moved into facility on November 8, 2021, and was sent to the hospital on January 6, 2021, but did not return to facility after hospitalization. According to interview with Administrator, R1 was refusing care since move-in date. Interview with staff present revealed resident was being changed multiple times per day but R1 did not allow staff to provide care multiple times per week. Records collected revealed that R1 was admitted to facility with a pressure injury, and such was documented as of November 9, 2021, by staff. Interview with outside source revealed that there was no indication that staff present would not change resident multiple times per day. Records also revealed that R1 was being treated for a pressure injury by a Home Health Agency (HHA) as of November 18, 2021. Records also corroborated that HHA was providing wound care on a weekly basis from November 18, 2021, until the week of January 4, 2022. It was also alleged that staff did not protect R1 from self-neglect. Interview with Administrator revealed that multiple agencies were advised of R1’s care refusal including R1’s Primary Care Provider (PCP), Home Health Agency (HHA) and responsible party (RP). Interview with staff present corroborated that PCP, HHA and RP were informed of R1’s care refusal. Interview with outside source revealed R1 was refusing care from HHA as well, including refusing catheter care. Outside source records corroborated that PCP was aware of R1 refusing care. Records collected corroborated that all agencies involved in R1’s care were aware of care refusal. Interview with outside source revealed that an outside agency and facility Administrator were attempting to relocate R1 in efforts to prevent R1 from self-neglect. Records collected corroborated that outside agency was attempting to find R1 different placement. Based on LPA's internal interviews, outside source interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Administrator Victoria Matic, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.