Complaint Investigation Report

Resident developed multiple pressure injuries due to neglect by staff.

On the allegation that Resident #1 (R1) developed multiple pressure injuries while in care due to negligent staff, it is the concern of the Reporting Party (RP) that R1 was observed to have various pressure injuries: Stage 3 and Stage 4 pressure injuries located in the areas of the left ankle, middle of the foot, and various stage pressure wounds of the left elbow, in-between the second and third toe of the right foot and the coccyx area due to staff neglect. To investigate the allegation, LPA Urena conducted interviews and record review. The LPA interviewed the Administrator about the pressure wounds, and the Administrator reported that R1 was admitted to the facility on 10/01/2024 with wound care and was receiving wound care from a Skill Nursing Facility (SNF) prior to admission and has continued to receive wound care from the Hospice and Home Health providers through the resident’s health provider, Kaiser Permanente. Staff’s interview revealed that they assisted R1 with repositioning throughout the day, keeping them clean and dry, and following Home Health nurse instructions. LPA Urena interviewed R1, and R1’s interview revealed that R1 is alert and oriented; R1 was able to understand and answer the LPA’s questions. R1 reported to be receiving very good care from staff. Staff assist with repositioning, incontinent care and transfer from bed to wheelchair, and staff take R1 to the backyard for fresh air as weather permits. Furthermore, R1 reported having a nurse who attends to their skin issues. LPA Urena interviewed the responsible party for R1, and the responsible party reported that R1 had developed pressure wounds before being admitted to the facility on 10/01/2024, however, the responsible party could not provide the stage of the pressure wounds, or location of the wounds. Furthermore, the responsible party reported that R1 has been receiving continuous wound care at the facility at least two times per week and has received wound assessments several times. Responsible party added that R1 was receiving good care at the facility and was informed anytime that R1 had a change in condition. Residents’ interviews revealed that staff take care of their needs and are responsive when the residents have a change in condition.

LPA Urena conducted record review of documents pertaining to the investigation:

Record review of Radiant Hospice Care Inc. (RHC) indicates that R1’s Effective Date of Certification was 09/21/2024 to 11/19/2024. Effective Date of Service was 10/03/2024. Certification was based on face-to-face encounter conducted on 07/23/2024. Plan of Care indicates that RHC was providing care to R1 for Hypertensive heart disease with heart failure, resident is non-ambulatory and spends most of their time laying down due to generalized body weakness.