Complaint Investigation Report

Regarding Allegation #1 : this investigation revealed that Resident #1 was admitted to the hospital on 08/21/20 with an open wound to the right hip – measuring: 8cm x 0.2cm. Upon discharge on 08/24/20, home health services were obtained, effective 08/25/20. Despite regular wound care by home health nurses, Resident #1’s right-hip wound worsened over time; and, the wounds increased in number to include pressure injuries on their bilateral heels. On Resident #1’s return from hospitalization on 08/25/20, there was an order for the fungal rash: cleanse with soap and water, pat dry, apply Miconazole Topical 2% and Calmoseptine, and leave open to air. Although, it is possible that Resident #1’s scratching of their wounds and fungal infection prevented the pressure injuries from resolving, it is more likely that unattended moisture and failure to reposition the resident every two (2) hours at night contributed to the progression of the pressure injuries. Witness #4 (Home Health Care Manager) believes the lack of frequent repositioning and keeping Resident #1 dry overnight was the primary reason why the right hip progressed from Stage II pressure injury at the beginning of home health services to an Unstageable pressure injury – measuring: 4.6cm x 1.8cm x 0.2cm by 09/14/20. As of 01/20/21, the right hip pressure injury remained Unstageable. The facility retained Resident #1; and, the resident’s pressure injury was over a Stage II, a prohibited health condition.

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

Regarding Allegation #2 : this investigation revealed that the Home Health Agency skilled nurse was aware that Resident #1 was not being repositioned overnight because there was no nighttime caregiver available. Despite regular wound care by the home health nurses, Resident #1’s right-hip wound worsened over time; and, the Home Health Agency skilled nurse recommended that Resident #1 be transferred to a higher level of care. This requirement is not met as evidenced by: Lack of frequent repositioning every two (2) hours and keeping Resident #1 dry overnight was the primary reason why the right hip progressed from a Stage II pressure injury to Unstageable.