Complaint Investigation Report

Allegation: Resident developed a pressure injury due to staff neglect.

The details of the complaint alleged that (R#1) developed a pressure injury due to staff neglect.

During the records review gathered by CCLD staff, the department observed that (R#1) was admitted to Above and Beyond hospice on 6/4/24. The hospice prescribed and delivered a low-air mattress; when the prescribed mattress was delivered, the delivery person set it up and needed to share with facility staff how to operate the mattress. In addition, the department observed the records requested by CCLD staff regarding (R#1)’s wound care company “Wound Pros” Nurse Practitioner (NP) notes on 6/26/24, (NP) indicate that she provided education regarding the management of (R#1)’s air loss mattress to facility staff. Moreover, the department observed on the Physicians Certification for Hospice Benefit dated 6/11/24 from the hospice Registered Nurse (RN) that nothing is written about educating facility staff on operating new air mattresses (R#1).

During an interview conducted by CCLD staff with facility administrator (A#1) on 7/31/24, she stated that when (R#1) moved into the facility on 3/30/24, they did not have any skin breakdown issues until transitioning to a new hospice agency (Above and Beyond Care) in 6/24/24. The new hospice agency provided a new air mattress that arrived on 6/5/24. When the delivery company dropped the bed off and, after setting it up, told the facility staff that the bed was ready for (R#1) to use. Neither the delivery company nor the hospice agency trained the facility staff to operate the mattress properly. (A#1) believes that the new air mattress was not set correctly and was too hard, causing (R#1) skin breakdown that led to a pressure injury. Moreover, (A#1) stated that on 6/26/24, a wound nurse from Wound Pros noticed the air mattress was not correctly adjusted and notified facility staff; the nurse properly adjusted the settings on the mattress and provided training to the facility staff on how to use the settings on the mattress properly.