Complaint Investigation Report

Emerald Valley staff first noticed redness on R1 bottom on 11/26/2023. Home health was requested on 11/28/2023 and a follow up was requested again on 12/7/2023, but services did not begin until 12/15/2023 after F1/Power of Attorney (POA) called R1’s doctor for a referral. Home health nurses visited R1 on 12/15/2023 and instructed staff to reposition R1 every two hours, and to change the dressing when it became soiled. Home health physical therapist found R1 sitting in R1 wheelchair, on R1 pressure injury, and reminded staff not to let R1 sit on R1 injury. R1 was admitted into the hospital on 12/20/2023 for low blood pressure, sacral pressure injury and blood in R1 urine. A hospital nurse (name unknown) staged R1 pressure injury as a stage 3, which was estimated to have been present for the past three weeks. R1 required debridement surgery and was discharged from the hospital back to Emerald Valley with hospice services. R1 was interviewed and said staff put R1 in R1 chair and R1 sat there all day. Staff always told R1, “We’ll get back to you,” when R1 requested help from them. R1, F1 and F2, frequently pressed R1 call button to request staff assistance but were rarely helped. Staff always said they were busy or made excuses. Emerald Valley caregivers were interviewed and admitted they found R1 lying in soiled diapers and soiled bedding on multiple occasions. NOC shift caregivers endorsed to AM and PM shifts to not put R1s water bottle on R1 bed as it often leaked and got R1 clothes and sheets wet. Because they could not transfer R1, they left R1 in wet clothes and bedding until the AM shift could change R1. Med techs were also interviewed and stated caregivers put off repositioning R1 because “R1 was too heavy.” Caregiver told me one of the other caregivers they need to constantly ask staff to reposition R1. Since staff rarely responded to their requests for help, F1 and F2 repositioned R1 themselves when they visited R1. Based on the information obtained, the findings are substantiated.