Complaint Investigation Report

Resident sustained pressure injuries while in care.

On the allegation of ‘Resident sustained pressure injuries while in care’, it is alleged that Resident #1 (R1) was admitted to the hospital with a wound on their left heel, and a sacral stage four (4) pressure injury. To investigate this allegation, LPA Urena requested hospital records and Home Health Services records for review. On 12/08/2021, the LPA reviewed the hospital records. Hospital wound care consultation records confirmed that R1 was admitted to the Emergency Room (ER) with a sacral stage 4 pressure injury, and a left heel wound. On 07/27/2022, the LPA requested Home Health Care Services (HHCS) records and conducted the record review on 08/05/2022.

On 12/02/2021, at 12:00 p.m., the LPA interviewed the administrator about the allegations. Per the administrator, R1 started receiving Home Health Care Services (HHCS) in June 2021 due to a surgical wound. At 12:06 p.m., the LPA interviewed the Responsible Persons (RP) for R1 about the physical condition of R1. The RP reported that they knew a nurse was providing care to R1 for a surgical wound but was not aware of the pressure injury. On 07/27/2022, the LPA interviewed representatives from the HHCS agency about the care provided to R1, and the communication with the facility’s staff in regard to R1’s condition. Per the HHCS representatives, services were provided to R1 from 6/30/2021 to 11/26/2021. Services for R1 were started due a surgical wound, and not for the sacral pressure injury. Furthermore, the HHCS staff reported that the RP, and facility staff were informed of the sacral pressure injury, which developed while R1 was in care.