Complaint Investigation Report

This page of the report is being amended on 06/03/2025 to correct a typographical error made while typing this report. The findings remain the same..

receiving home health services for a stage 1 pressure injury on the buttock area prior to hospitalization. R1 was hospitalized from 04/07/2023 through 04/22/2023 for respiratory failure. On 04/21/2023, home health services were discontinued. R1 was re-hospitalized on 05/04/2023 for pneumonia and other medical conditions. At the time of admission, the hospital indicated there were no pressure injuries upon re-admission. On 05/06/2023 (two days later) medical records referenced a pressure injury on the coccyx, which was initially not staged and upon discharged was staged as a stage 2. On 05/19/2023 R1 was discharged to a skilled nursing facility with documentation of a stage 2 pressure injury near/on the coccyx.

The investigation identified inconsistencies and discrepancies in medical records from the hospital. Based on the documented timeline, R1 was hospitalized during the periods necessary for the development of a stage 3 pressure injury. Additionally, the allegation alleged a stage 3 pressure injury developed on/near R1’s buttock area which based on medical records from the hospital and home health has never been the case. Based on the investigation conducted by the Investigations Branch and the review of medical records, there is insufficient evidence to support the allegation that R1 developed a stage 3 pressure injury while in the care of the facility. Therefore, the allegation is unsubstantiated at this time.

An exit interview was conducted, and a copy of the report was provided.