Complaint Investigation Report

Allegation: Resident (R1) developed stage 3 pressure injury while in care.

Medical records revealed that R1 was admitted to the hospital on 3/17/23 due to acute cholecystitis. R1 informed the nurse about having the pressure injury prior to being admitted to the hospital. R1 was developing a coccyx deep tissue pressure injury and was provided home health services when R1 was discharged back to the facility on 3/17/2023. The Department observed that the medical records do not indicate that R1 presented at hospital on 3/17/23 with a pressure wound. The medical records indicate that a developing wound was noted after hospital admission; that R1 was discharged back to the facility with Home Health orders; and that Home Health records noted progressive healing, and was healed at the time of Home Health discharge in June 2023.

Interviews with S1, care staff and med-techs (S2, S3, S4, S5, S6 and S7) revealed consistent statements of R1 refusing to be transferred and requiring staff assistance to be transferred from R1’s recliner, bed, and toilet. Staff denied remembering that R1 had a stage 3 pressure injury. S1 denied knowing the stage of R1’s pressure injury despite HHN confirming that S1 saw R1’s pressure injury and was aware that R1’s wound was a stage 3. HHN visited R1 frequently and treated the pressure injury. HHN did not believe the facility staff contributed to R1’s pressure injury developing into a stage 3. R1’s pressure injury responded well to the treatment by HHN which healed by June 2023. HHN did not have any concerns regarding facility staff and care of R1’s pressure injury. Therefore, the allegation is unsubstantiated.

Allegation: Staff do not assist resident (R1) with incontinence needs.

Reporting party (RP) stated the night staff tell R1 to wet her bed instead of getting her up to the restroom. RP further stated that the morning staff stated they saw R1 had been sitting in her feces, and the night shift did not change her. Review of records showed FM1 brought up these issues to the previous ED. FM1 sent email to previous ED stating R1 was not refusing to go to the bathroom with the bedside commode and wanted the staff to ‘ignore’ R1 and get R1 up to toilet.