complaint·March 23, 2022

Continued from 9099 Allegation- Neglect/lack of supervision resulted in resident in care sustaining pressure injury. LPA interviewed the home health nurse for R2 and staff, reviewed time sheets, resident's Assisted Daily Living Logs (ADL), Home Health notes, Progress and daily shower logs. File review and interviews indicates that upon admission resident R2 was identified as being non-ambulatory, but at some point became unable to bear weight. Staffing progress and charting notes indicate that staff were providing assistance with daily hygiene needs and identified a rash on 9/15/21. Facility requested home health services for R2. Home Health initiated 9/26/21, and on 10/8/22 the home health nurse who assessed resident noted that they were treating resident for a rash. Due to conflicting statements and documentation of hospice agency. LPA is unable to determine whether resident sustained a pressure injury. Therefore the allegation is UNSUBSTANTIATED. Allegation- Neglect by staff resulted in injury of resident. LPA interviewed staff and reviewed records. File review indicates that resident R3 was identified as being a fall risk by their hospice agency and encouraged that safety precautions be in place. Per interviews with staff, resident had a one on one personal staff during the day, and was encouraged to join activities. During the NOC shift, records indicate that R3 received hourly checks. Interviews also reveal that during the alleged incident, R3 was engaged in activities and surrounded by other residents and staff. Therefore this allegation is UNSUBSTANTIATED. A finding that the complaint allegations: Neglect/lack of supervision resulted in resident in care sustaining pressure injury and Neglect by staff resulted in injury of resident was unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegations occurred. No deficiencies cited during this visit.