complaint·March 1, 2024

Regarding the allegations: Staff are not ensuring that resident is provided with a comfortable mattress and Staff are not addressing resident's burn injury it is the reporting party’s concern that Resident #1 (R1) had sustained level one degree burns on their elbow and their left side of their body from their mattress. To investigate the complaint the LPA conducted a tour, conducted a file review of R1’s records, and conducted interviews. At 10:30 a.m. the LPA conducted a brief tour of R1’s bedroom and observed R1’s bed. The LPA observed a thin air mattress on top of a foam mattress. The LPA touched the air mattress, and the foam mattress and both mattresses did not feel hot. The LPA did not observe or felt any heat coming from the mattresses and did not feel any metals inside the air mattress. File review of R1’s records revealed that R1 is on hospice and has a doctor’s order for a hospital bed with half rails and an alternating pressure (APP) mattress from their hospice agency. Staff interviews revealed that they have not seen any burn injuries on R1 or any other resident. In addition, the administrator stated that residents on hospice are provided with beds from their hospice agencies. Interview with R1’s hospice nurse, revealed that R1 is seen once a week or as needed, a full body assessment is done at every visit, and R1 has not been observed with burn injuries. R1’s hospice nurse also revealed that R1 has a callus on their left elbow from always having their elbow on the same place and lack of circulation. Furthermore, the hospice nurse revealed that R1’s skin is looking better, and that even though R1 is a high risk for skin problems and that the bed is helping they can replace the bed at any time if there’s any concerns. Lastly, R1’s case manager from R1’s conservator’s office revealed that they do not have any concerns regarding R1’s bed causing the resident burns. Based on the information gathered, although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that a violation occurred; therefore, the allegations that " Staff are not ensuring that resident is provided with a comfortable mattress” and " Staff are not addressing resident's burn injury,” are deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.