Complaint Investigation Report

Allegation: Staff did not ensure resident was rotated resulting in resident developing multiple pressure injuries

During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1, S2, S3, S4) & R1’s responsible party (POA) and reviewed R1’s documents. Review of R1’s records showed he was admitted at the facility on 04/01/2023 and resided at the facility until 12/30/23. R1 was assessed as having dementia, non-ambulatory, needs assistance transferring in & out of bed, on a special diet of pureed foods and did not have a history of skin breakdown. On 12/31/2023, R1 was admitted at the hospital for treatment of acute kidney injury. While at the hospital, R1 was diagnosed with a total of 2 unstageable pressure injuries on his left and right heel. S2 confirmed with the department that she was aware of R1’s pressure injuries on his left and right heel but did not report her findings to the administrator (ADM) and licensee or other staff (S1) because R1’s injuries were already healed. R1’s responsible party (POA) stated that R1 sustained another pressure injury on his butt in October 2023 while at the facility. Staff notified her of the small pressure injury on R1’s butt and instructed her to buy cream to help the pressure injury heal. It was also found that R1 was receiving home health services for physical therapy but was not receiving wound care. R1 started receiving wound care on 12/31/2023 when he was diagnosed with unstageable pressure injuries at the hospital. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not ensure resident was rotated resulting in resident developing multiple pressure injures was found to be substantiated.

Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in developing multiple pressure injuries while in care. Additional civil penalty related to serious bodily injury is pending review.