Complaint Investigation Report

Regarding the allegation: Due to lack of care, resident wounds progressed to pressure injuries while in care

The investigation revealed that prior to residing at this facility, R1 was at a skilled nursing facility (SNF) from 12/09/2021 – 12/25/2021, with the admitting diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side. Medical records from R1’s stay at the SNF indicated that R1 required wound care for ‘multiple trauma wounds’ on the left elbow, left knee, left lower chest, right knee, right elbow, and left dorsal foot trauma wound. The above-mentioned wounds were not documented as pressure injuries. R1 was discharged from the SNF with an order for physical therapy and wound care.

R1 began to receive home health services on 12/25/2021, which was the same day that R1 was admitted to this facility. At the start of care, R1’s wounds were noted as follows: left chest wound (11x3cm), left elbow wound (4x3.2 cm), left knee wound (2x1.5x0.2cm), left medial knee (2x1.7cm). However, these were considered trauma wounds and were not documented as pressure injuries. On 12/25/2021, home health staff completed the “Braden Scale for Predicting Pressure Sore Risk in Home Care”, and R1 had a total score of 12, which was indicated as “high risk” for pressure injuries. At the start of R1’s home health services, R1 was visited by a home health nurse daily to care for R1’s wounds. A nursing visit from home health conducted 12/27/2021 reported that R1 also had a stage 2 pressure injury on the left buttocks.

To supplement such care, facility staff were expected to ensure that R1 was hydrated and regularly repositioned to aid in the treatment of wounds. Yet, a home health visit dated 1/8/2022 indicated that R1’s wounds had progressed to the following: stage 3 pressure injury to the right knee (2x1.7x0.3) with a moderate amount of drainage, stage 2 pressure injury to the sacral (3.8x1.2x0.3cm), stage 3 pressure injury on the buttocks (3.2x1.3cm), stage 4 pressure injury to the left elbow (3.0x3.0x0.4cm) with a moderate amount of drainage. It was further noted that R1 required skilled nursing for wound treatment. Interviews and records review confirmed that on 1/9/2022, witnesses observed a sealed bag of disposable bed pads being used to prop R1 up instead of pillows. Home health records indicated that staff ‘refused to assist to turn the patient’ in claims that they had already performed wound care. Records from 1/21/2022 stated that R1’s pressure injury at the sacral had progressed to a stage 3, and the wound on R1’s elbow was progressing to a stage 4 pressure injury. It was documented in records on 1/10/2022 that R1’s wounds worsened despite communicating the rotating schedule to staff and demonstrating proper positioning.