Complaint Investigation Report

Highland Hospital medical records revealed that on 12/7/2023 R1 was transported from his care facility via ambulance with the chief complaint of sustaining a fall in the bathroom of the facility on 12/6/23. R1 was admitted and diagnosed with two stage three pressure injuries on his sacrum and left hip. R1 was not on hospice or receiving home health for his pressure injuries.

An interview with S1 revealed that she was aware that R1 had a pressure injury on his hip and buttock area observing the wounds while giving R1 a bath on 12/6/23. S1 stated that she felt she could manage the wound care for R1. R1 was not receiving wound care from anyone other than S1. S1 stated that R1’s pressure injuries developed on 12/7/2023. S1 denied tha t R1’s pressure injuries were in the condition that Highland Hospital documented and photograph ed from R1’s hospital visit on 12/7/2023. S2 denied seeing any marks on R1’s body while giving him a shower on 11/30/2023.

Allegation: Staff did not ensure a resident had timely medical appointments

Review of R1’s file revealed that R1 was last seen by his primary physician on 7/23/23. No other medical visits were made despite R1’s declining health. S1 stated during the initial 10-day visit that she did not notify anyone or do anything about the resident’s decline. She stated, “I waited too long” and “I should have done something more” and other similar statements.

Allegation: Staff did not address a resident's change in medical condition

An interview with S1 revealed that she was aware of R1’s declining health over the past 5 years but did not take R1 to any medical appointments during that time with the exception of his yearly physical. During his yearly physical S1 did not bring up her concerns about R1’s declining health to his PCP.