Complaint Investigation Report

On 03/05/21, a subsequent tele-visit was conducted by Investigator Jose Santana, during the visit, Investigator Santana interviewed staff from staff#1 (S1) to staff #21 (S21) which included Administrator Pamela Parsons; interviewed resident’s representative (RR); interviewed social worker (SW); obtained records from staff#9 (S9) and staff#20 (S20) to staff#23 (S23); and obtained records from police department (PD), hospital’s social worker (SW) and fire department (FD). IB reviewed resident#1 (R1)’s facility file and related documentation. Department was unable to interview resident#1 (R1) because R1 was passed away on 03/15/21.

Regarding allegation: Resident sustained multiple severe pressure injuries while in care.

It was alleged that a resident had multiple pressure injuries from resident’s leg, back and buttock area while in care. During the investigation, the department interviewed staff (S1) through (S21), reviewed R1’s facility file and reviewed documentation from outside providers. Per staff interviews, R1’s home health representative indicated they were not aware of R1 pressure injuries, were not notified by the facility of R1’s pressure injuries and did not receive any orders to treat R1’s pressure injuries. Home health staff were notified by the facility of R1s pressure injuries on 02/25/21. Interviews with staff revealed that not all staff were not made aware of R1’s pressure injuries and administrator failed to communicate R1’s pressure injuries to facility staff and with R1’s home health agencies. Per file reviews, on 02/10/21, R1 had redness on buttocks. On 02/18/21, S4 and S6 were aware of R1’s pressure injuries on resident’s back/buttock area. The facility did not address or document R1’s pressure injuries on R1’s care plan and did not notify R1’s family or responsible party of R1’s declining health and pressure injuries. On 02/25/21, S4 reported the resident had skin breakdown on resident’s hip and then notified R1’s home health care. On 02/26/21, the home health nurse came to assess R1 for pressure injuries and reported R1’s had unstageable pressure injuries on the resident’s back/buttock area and left heel. Although the facility contacted home health on 02/19/21, a home health assessment of R1’s pressure injuries was not obtained until 02/25/21. Thus, R1 developed multiple severe pressure injuries, an unstageable pressure injury to the back, buttock area and left heel, due to staff failing to address R1 pressure injuries in R1’s care plan and did not obtain home health for R1s pressure injuries upon first knowledge of R1s pressure injuries on 02/18/21.

Regarding allegation: staff did not seek medical attention for resident in a timely manner.

It was alleged that facility staff failed to provide timely medical care to resident who had several pressure injuries, including unstageable pressure injuries. The department interviewed staff (S1) through (S21), reviewed R1’s facility file and reviewed documentation from third party providers.