Complaint Investigation Report

Regarding Allegation #1 : this investigation revealed that Resident #1 (Referred to as R1) was a resident at the facility and was receiving home health care services. R1 was admitted to the hospital on 02/25/21 for multiple pressure injuries: Left lateral knee (Stage 2); Left foot (purple); Left hip (unstageable); Right heel (purple); Right lateral malious (purple); Right lateral foot (purple-deep pressure injury); Right medial foot (marron); Right hip (unstageable); Left lateral calf (stage 2). On 02/22/21 R1’s diagnosis elevated to a right hip pressure ulcer – Stage 4 (measured: 5x5.5 x 0.8 cm) with moderate purulent drainage with foul smell; left hip (measured: 7 x 6.5 x 0 cm) covered with yellow and gray slough (100% with moderate purulent drainage and foul smell). Right hip pressure ulcer Stage 4 (measured: 5cm x 5.5cm x 0.8cm) with 60% red wound bed and 40% yellow slough. Left hip pressure ulcer (unstageable) – measured: 7cm x 6.5cm x 0cm covered with 100% yellowish slough (now, almost double in size) with foul smell. Facility staff were assisted weekly by Home Health Agency (HHA) skilled nurse who worked together to provide care for R1. In addition, weekly training was being provided to facility staff as to the needs of R1. Facility staff applied first aid and would reposition R1 every 2 hours to prevent further injury. The care plan explains the care provided to R1 by the HHA skilled nurse and facility staff which was consistent with documentation in R1’s care plan instructions. Facility staff reported that R1 would regularly remove its diaper and scratch its wounds and was unwilling to allow the HHA skilled nurse to perform wound care.

Based on the evidence gathered, interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident sustained multiple pressure injuries while in care is found to be SUBSTANTIATED.