Complaint Investigation Report

The investigation revealed the following. Regarding the allegation “Resident sustained multiple pressure injuries while in care.” It is being alleged that resident R1 developed stage 3 and/or stage 4 Pressure Injuries while in care. The Department reviewed R1’s records, home health records and hospital records,and records indicate that R1 did not develop a stage 3 or 4 pressure injuries while in care and during R1’s hospitalization on 06/29/2022. Home Health Records indicate that R1 was being provided wound care for an unrelated injury between 04/22/2022 and 06/27/2022. Hospital Medical Records indicates that during R1’s hospitalization on 06/29/2022 the hospital wound care nurse assessed that R1 had a wound indicative of a stage 2 pressure injury, there was no documented evidence that R1 had a stage 3 or 4 pressure injury prior to R1’s admission at College Medical Center. Hospital Medical records also indicates that R1 was discharged from College Medical Center and admitted to Kindred Paramount Hospital on 07/14/2024. On 07/15/2024 Kindred Paramount Hospital staff diagnosed R1 with multiple unstageable injuries on R1’s back. Interviews revealed the following: R1’s unrelated wounds were healed and R1 was cleared by home health before R1 was sent to College Medical Center. 7 out of 7 staff indicate that R1 did not have a pressure injury prior to being admitted to the hospital. Staff denied the allegation and reiterated that they would have seen R1’s lower back area several times per day. Staff indicated that a home health nurse was treating wounds on the front of R1 upper thigh and R1 skin area. S3 performed diaper changes on R1, and this involved repositioning R1, cleaning and drying R1. S3 did not see any skin breakdown for R1.