Complaint·September 22, 2022

According to staff, to alleviate pressure in bed and prevent R1 from developing pressure ulcers, facility requested a hospital bed with pressure relieving mattress, staff turned and repositioned R1 every 2 hours and provided incontinence care every 2 hours to ensure R1 was cleaned and dry. Based on documents provided by the facility, on 3/5/2022, facility staff noted R1 developed a pressure ulcer. The facility staff completed a change of condition and notified R1's physician. While waiting for the physician to respond, facility provided treatment to R1's wound. Subsequently, R1's physician ordered a home health referral for wound evaluation and management. In addition, facility conducted a virtual appointment with R1's physician and R1's responsible party concerning the pressure ulcer. On 4/18/2022, R1's wound was noted to be stage 3 by the home health nurse and R1 was transferred to the hospital on the next day for worsening of the wound. Base on record review and interviews during the course of investigation, this allegation is unsubstantiated as the facility provided actions to prevent R1 from getting pressure ulcers but due to R1's health condition, R1 developed pressure ulcer and when it was noted by the facility, the facility took actions. Although the above investigations 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. This report is discussed and reviewed with the administrator. A copy is provided.