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32 | The reason for the amendment is to remove confidential information. The finding will remain unsubstantiated. See hard copy for signature. In regard of allegations: Resident sustained unexplained injuries and Staff did not report incidents to authorized representatives. It was alleged that R1 was observed with bruises, lacerations, and skin tears and staff didn’t provide timely and accurate report to residents representative.
During the investigation, the LPA interviewed the Administrator, staff, residents, and family members. The Administrator and staff denied the allegations. They stated that staff at the facility have not caused any injury to R1 or any other resident and that staff always provide timely and accurate reports to residents’ representatives. R1 was admitted to the facility on 06/29/25 under Hospice care with a history of skin condition and with a G-tube. Administrator stated that R1 had existing bruises due to prescribed blood-thinning medications that were administered per Hospice orders. The Administrator also stated that R1 had sensitive skin and frequently experienced itching and scratching. According to the Administrator, the itching was a side effect of prescribed medications. LPA spoke with Hospice nurse and reviewed R1’s file and Hospice documentation, which explained why R1 is prone to bruising easily. From discussions with the hospice nurse and a review of hospice and facility documentation, LPA learned that certain medications prescribed by the physician may cause side effects such as itchy skin, rashes, and increased or unexplained bruising, which can make it easier for blood to pool under the skin. They stated that they were at the facility often and were in communication with the staff and R1’s family members. Hospice nurse stated that they didn’t observe any neglection from facility administrator and staff. However at the time of visits specifically on the dates of 8/16/25 8/18/25, 8/20/22 and 8/27/25 they observed evidence of cellulitis, skin discolorations, left jaw swelling likely related to bed rail contact and a left calf wound which was later ruled out. At the time of conversation nurse expressed an opinion that skin discoloration and jaw swelling were because of side effects of medications that were prescribed by the doctor. They may cause unusual bruising or bleeding on the skin, may cause hives or itching as a reaction. Also they mentioned that calf wound was the result from the compression wraps. Nurse stated that observations were communicated with facility staff and R1’s family members and proper care was continuously provided to R1. The hospice nurse further stated that R1’s family expressed no concerns regarding the care provided by hospice and facility, which supported that the issue stemmed from a miscommunication between the facility and hospice rather than lack of proper care. LPA also spoke with R1’s responsible party, who maintained regular contact with R1, Hospice agency and the facility staff. The responsible party explained possible reasons why R1 sustained bruising on their body and skin.
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