Complaint Investigation Report

Regarding allegation - Resident is not being rotated resulting in pressure injuries. The Department of Social Services Investigation Branch (IB) Investigator, Peter Zertuche, conducted interviews and obtained medical (Hospice) records for Resident #1 to determine the findings of this allegation. The information obtained from the interviews revealed that Resident #1 was not being rotated resulting in pressure injuries. Per the Mt. Olive’s Hospice agency care plan, Resident #1 was admitted to this hospice agency with a stage 2 wound in the coccyx area on 12/21/2020. The notes stated to rotate every 2 hours and to change diapers often to ensure the coccyx area is dry at all times. The interviews revealed that caregivers did not change the diaper nor reposition regularly during some shifts. Per interview with Resident #1’s family member, the individual stated no staff came in to check on resident while visiting for 4 hours on one of the visits. Although Staff interviewed denied not rotating resident every 2 hours, the resident’s wound eventually worsened to a stage 3 by 2/1/21. There was no new plan of care or contact with the doctor once the wound worsened. Based on interviews and record review, there are supporting evidence to substantiate this allegation.

Regarding allegation - Resident’s diapering needs are not being met. LPA reviewed Resident #1 facility’s Service Plan and hospice visit notes which indicated that Resident #1’s diaper needs to be changed often to keep buttock area dry, preventing the open wound to occur or get worse. LPA Chan interviewed 3 care staff who stated they changed Resident #1 every 2 hours. Interviews conducted by Investigation Branch (IB) Zertuche also revealed that Resident #1 was found with soiled diapers during some visits by the hospice nurse and/or shift change of staff. According to the Mt. Olive’s Hospice Agency notes, the hospice nurses documented Resident #1’s diaper being soiled for at least 5 of their visits. It was also noted that Resident’s dressing in the buttock area was soiled with urine and/or feces while being changed by the hospice nurse. Based on documents and interviews gathered, there is sufficient evidence to show that the resident’s diapering needs were not met.