complaint·November 1, 2024

Continued from 9099... Documentation of shower refusals shows that witness (I1) was present during at least one of the shower refusals. On 7/21/24 resident received a shower by the Health and Wellness Director (HWD). HWD noticed scratches on R1’s back and torso. HWD questioned staff and witnesses I1 and I2 about the scratches. HWD discussed with I1 and I2 possibly changing laundry soaps and HWD took pictures to send to R1’s Primary Care Physician (PCP) to try and figure out what was going on with the scratches. HWD never heard back from the PCP or I1 about the cause of the scratches. One week after the discussion, R1 went to the hospital for a fall. During investigation, LPA reviewed charting progress notes and Incident reports submitted to CCL. On 7/30/24 R1 had a fall resulting in head injury and was admitted to the hospital. LPA reviewed hospital discharge papers. Per discharge papers, R1 was treated for a fall, head contusion, and dizziness, no mention of scabies in discharge papers. On 8/1/24 R1 returned to facility. According to charting progress notes, on 8/2/24 and 8/3/24 R1 mostly stayed in their room and R1’s head dressing was attended to by staff. On 8/4/24 R1 went back to the hospital due to staff noticing R1 speaking and acting in an altered state of consciousness. On 8/6/24 charting progress notes indicate facility LVN (S1) called hospital to inquire of R1’s status, S1’s charting progress note indicates R1 is being admitted for cellulitis. LPA unable to obtain discharge papers for hospital visit on 8/4/24. R1 never returned to the facility. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Complaint alleges due to staff neglect, resident sustained a pressure injury. Complainant states they observed a dime sized wound on R1’s back and on R1’s arm. During investigation, LPA reviewed charting progress notes and obtained photograph of R1’s arm, no picture of R1’s back was available. Per LPA observation, wound on arm does not appear to be a pressure wound as slough does not appear to be present, and no appearance of drainage or blisters observed. Per LPA review of charting progress notes, staff documented at least weekly observations, if not daily, of R1’s behavior and care needs. Charting progress notes do not reflect observation of pressure wounds. LPA review of 7/31/24 hospital discharge papers does not indicate any pressure wound observed or treated. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Administrator and a copy of this report was given .