Complaint Investigation Report

The investigation revealed the following: Regarding the allegations that Resident sustained pressure injury while in care and Staff did not seek medical assistance for resident in a timely manner. It was alleged that before R1 death R1 had “gurgling noises”, had a vaginal bleeding and was in severe pain many times and facility staff never called a doctor for pain,bleeding or for aspiration. Also, it was indicated that R1 developed a sore on her foot. R2 had a low blood pressure and staff said that they not going to call 911 and were not going to give blood pressure medication.

Interviewed Administrator and Assistant administrator denied the allegation. They stated that both residents were under the same hospice care: “Comfort Hospice Care”, and they were instructed to call hospice 24/7 for any reports/significant changes, which they did. Hospice nurse visited residents twice a week and staff always contact / report to the hospice when they noticed any significant changes on R1 and R2. LPA obtained and reviewed Hospice notes for R1 and R2. For R2 it said that at the time of nurse visits on 2/1/2019 ”vital signs are low but are still within normal parameters including blood pressure”. R2’s daughter requested doctor’s visit and the visit scheduled at the next day. Hospice MD was notified and obtained new order for R2. Administrator stated that R1 was incontinent and when staff changed the resident, they never noticed that R1 was bleeding. Review of hospice agency documentation shows that R1 never had vaginal bleeding. Hospice documents showed that R1 started continuous care (round a clock nursing supervision) from 5/28/2019 – 5/30/2019 because of R1’s last stage of their life. Patients/residents declining and last stage of their life they always have moaning and gurgling noises. The gurgling noise is due to patient unable to swallow their saliva. R1 admitted under Comfort Hospice Care as of 04/08/2019. Per Register Nurse's Initial evaluation and head to toe assessment patient did not have any wounds but had very sensitive skin and on high risk for open wounds. R1 transferred to facility with DTI (Deep Tissue Injury) which is very common for patients with CVA (cerebral vascular accident) diagnosis. Patient never had a pressure ulcer not in the hospital (from R1 was transfered to the facility), not at the facility. On 05/24/2019 report from visiting nurse said that R1’s Left Foot Deep tissue injury has opened and is now a Stage II Left foot pressure ulcer, which is very common with bed bound patients /residents. Wound has been treated appropriately and reported to doctor. For the pain R1 was prescribed Tylenol, Tramadol and at the letter time Morphine for lot of pain by the Hospice Doctor.