Complaint Investigation Report

During the course of investigation, the Department obtained copies of R1’s documents including but not limited to the following: medical records; LIC601 Identification and Emergency Information; Admission Agreement; LIC602A Physician's Report; Pre-placement Appraisal; hospital documents. Copies of LIC9020 Register of Facility Clients/Residents and LIC500 Personnel Report were obtained, and interviews conducted.

Medical records showed R1 was admitted to the hospital on 3/09/2021 with generalized buttocks pain. R1 was observed with skin breakdown but no pressure injury, wounds or incision. Medical records also revealed R1 had large amount of soft stool that appears to have been on R1’s skin for some time as it was difficult to remove and dried in some areas. R1 indicated that he tell the facility staff that he had bowel movement but sometimes it takes a while for them to clean him up. Staff (S1) stated when R1 moved-in, R1’s hospital bed and lift was not delivered that night and R1 slept in a wheelchair all night, because the facility didn’t have a lift. R1 was discharged back to the facility on 3/10/2021 with after care instructions on how to care for non-specific dermatitis.

On 03/30/2021, R1 was visited by Home Health at the facility and was observed with altered mental state. R1 was sent out and admitted to the hospital with final diagnosis of severe sepsis with acute organ dysfunction and unstageable pressure injury of sacrum/buttocks.

Staff interviews were conducted, and staff (S1 & S2) had a hard time recalling if R1 had pressure injury. S1 indicated that on the day of admission to the facility, R1’s hospital bed was delivered but not accepted by the facility due to bed was not electric.