Complaint Investigation Report

The Department interviewed the following: staff members on 5/31/23, 6/19/23 and 7/11/23; home health staff (HH1 and HH2) on 4/19/23, 5/04/23 and 6/20/23; residents (R2 and R3) on 5/31/23.

Allegation: Resident (R1) developed pressure injuries while in care.

On 10/10/22, R1 fell from the bed, was transferred to hospital, and diagnosed with hip fracture. R1 had hip surgery and was discharged back to the facility. R1 was followed by home health for her wound care and to remove staples from surgery. R1 developed pressure injuries while with home health care. Home Health (HH1 and HH2) provided instructions to caregivers on how to care for the pressure injuries and instructed the caregivers to elevate R1’s legs and heels so the pressure injury could heal. HH1 stated that R1 was known to refuse to be turned, refuse to have the dressings changed, and that R1 was combative towards HH1.

Interviews with staff (S3 and S4) confirmed that they were rotating R1 as directed by R1’s doctor’s and home health orders. Staff were also changing R1’s bandages in-between home health visits, when R1’s bandages became soiled or were coming off. Staff were using booties and pillows to float R1’s heels off the bed to further prevent the pressure injuries from getting bigger. An interview with facility manager, S1, revealed that staff were cleaning R1’s injures with saline solution as directed by home health to keep the wounds clean. The facility also provided R1 with booties for her heels when the equipment was not available from the home health agency.

Based on all information obtained, the allegation is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.