Complaint Investigation Report

A review of medical records conducted by the LPA Tan on 03/12/22 at 9:30 AM, revealed that R1 had a surgery for a broken ankle on 06/03/20 and was discharged from the hospital on 06/09/20 to the facility with assigned Palliative services upon discharge. Prior to admission, R1 had an existing pressure injury on the heel due to surgery and Stage 2 pressure injury on coccyx. Palliative care nurses were treating pressure injuries on R1’s coccyx and other locations. Hospital record review however, revealed that on 07/18/22 at 10:02 PM, R1 was admitted to the hospital with wound infection and sepsis due to unstageable pressure injury of back covered by slough/eschar, stage 4 pressure injury at right heel and stage 2 ulcer of left foot.

Based on record review, R1 was admitted to the facility with stage 2 pressure injuries. While in care of the facility, between 06/09/20 and 07/08/20, pressure injuries developed into higher stages. Subsequently, R1 was hospitalized due to infected wounds and sepsis.

Based on interviews and record review, there is a sufficient information to support the allegation. Therefore, the allegation deemed substantiated at this time.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.