Complaint Investigation Report

Regarding allegation: Resident developed multiple pressure injuries. It is alleged that R1 developed additional pressure injuries while in care. The investigation revealed the following:

Assistant Administrator S1 stated that a resident arrived at the facility on 09/28/2020 with a wound. According to Administrator, wound care was being provided by Pacific Pace, and a referral to Mission Hospice was completed on 10/01/2022. Wound care was approved effective 10/03/2020. LPA reviewed facility progress notes and Hospice documentation for R1 dated 10/06/2020 through 03/21/2021. Documentation of all care for R1 was received. Documentation from Hospice detailed daily wound care performed which included: removing soiled dressings, cleaning the wound(s), applying medicated creams, and wrapping the wound. Five of five staff (S1-S5) stated that no resident had developed a pressure injury while in care. LPA interviewed two residents with current wounds, and two of two residents (R2-R3) stated they arrived at the facility with wounds, and did not develop wounds at the facility. R1 was admitted on 09/28/2020 to facility, and LPA was unable to interview R1 due to R1’s passing on 04/24/2021.

LPA also interviewed an additional five residents (R4, R5, R6, R7,R8) who stated they did not know of any residents with pressure injuries, and they do not have pressure injures. LPA reviewed documentation from Pacific Pace and Hospice, along with R1’s medical records that documented R1’s wound(s) prior to being admitted to facility. Interview with overseeing wound care physician stated that R1 did not develop any pressure injuries while in care at facility. Also, no documented evidence was discovered that indicated R1 developed pressure injuries while in care at the facility. Based on interviews conducted with facility staff, Hospice physician, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

Regarding Allegation: Staff are not preventing the spread of infection. It is alleged that facility did not prevent the spread of infection, and that bodily fluids on the floor of resident’s room was being stepped on by staff, and taken to other rooms of facility.

Assistant Administrator S1 stated that they have an Infection Control Plan. LPA reviewed Infection Control Plan, and all five of five staff stated that they follow the Infection Control Plan to prevent infection. LPA observed a large bin in a secured area where all bio hazard material is place for disposal. Five of five staff stated there are specific procedures to prevent the spread of infection, and denied walking, or seeing others walk, or step into bio hazard liquids. Two of two residents who are currently receiving wound care stated, all bio hazard material is disposed in a proper manner. Residents (R4, R5, R6, R7, R8) stated that facility does everything they can to prevent the spread of infection. LPA toured facility with Assistant Administrator and did not see any infectious material or fluids anywhere in facility rooms, or common areas.