Complaint Investigation Report

Allegation: Resident (R1) developed stage 4 pressure injury while in care.

R1 was admitted to the facility on 1/08/22, and the Pre-placement Appraisal did not indicate that R1 had a pressure injury, however, the LIC602A Physician’s Report indicated that R1 had contractures to the upper and lower extremities, required continuous bed care, had fragile skin and needed to be repositioned every 2 to 3 hours.

John Olivarez, licensee, stated that R1 has dementia, was bed bound and fully contractured when admitted to the facility and that R1 was always in fetal position. Licensee stated R1 was admitted to the facility as it was their hope that R1 could get to the point where R1 could sit up on her own. R1’s pressure injury was reported to him by staff which at the time he believes it was stage 1. The pressure injury worsened

Staff (S3) stated she does not believe R1 should be admitted to the facility because S3 felt that R1 needed a higher level of care. R1 has dementia and needed assistance with all activities of daily living, with both feet and hands being contractured, and R1 was difficult to reposition. S3 also stated that the first person to notice the pressure injury was R1’s previous caregiver - when this private caregiver visited R1 and changed R1’s diaper and reported the pressure injury to her. S2 stated having noticed the wound which was approximately the size of a quarter. R1 had home health but S2 was not able to report anything because she never saw them, or she was busy assisting other residents. Between the time R1’s home health was terminated to the time R1 was hospitalized, S2 was cleaning R1’s wound. In September 2022, S2 noticed R1’s wound grown to about the size of a golf ball with soft center and had some pus.

Two out of 3 residents interviewed did not know or remember R1 while the other 1 stated R1 can walk but R1’s documents and staff interviewed stated R1 is bedridden.

Previous administrator (S1) stated R1’s daughter requested ambulance transportation on September 2022 to the hospital per advice nurse and R1’s doctor. Medical records showed R1 was admitted to the hospital on 9/16/22 and diagnosed with stage 4 sacral pressure injury and unstageable pressure injury at right lateral pelvis.