Complaint Investigation Report

On 9/30/21, LPA Chan conducted an on-site visit to interview 4 Staff and 10 Residents. LPA requested for the staff roster, resident roster, and facility notes pertaining to Resident #1. The allegation – Resident is not being rotated resulting in pressure injuries was investigated by an Investigation Branch personnel.

The Investigation revealed the following:

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 updated care plan nor contact made with the doctor once the wound worsened. Based on interviews and record review, there are supporting evidence to substantiate this allegation.

For allegation – Resident’s medication is not being administered. It was alleged that Resident #1 (R-1) did not receive insulin on a daily basis. According to interviews conducted by LPA Chan, R-1 was able to self-administer the insulin until R-1’s health condition worsened and could no longer administer consistently. A Med Tech confirmed that due to the facility staff not being skilled professionals to inject the insulin on the resident, the hospice nurse came to administer the injection when they were called. Based on facility’s medication record and hospice notes, the medication that requires injection, Insulin Lispro 100/ML 5X3 ML was not consistently taken in December 2020 to January 2021. The notes on the MAR logs indicated the medication was either withheld due to the blood sugar level, R-1 refused, or that R-1 was physically unable to take. Based on the information gathered, R-1 did not take the injection daily as ordered by the physician and the hospice care plan did not state the hospice nurse was responsible for providing the injection on a daily basis. There is sufficient evidence to substantiate this allegation.