Complaint Investigation Report

Information obtained from the interviews conducted and records reviewed revealed the following: Staff 1 (S1) observed the development of the pressure injury approximately the first week of May 2021 and provided treatment to the pressure injury. S1 expressed observing the area of the pressure injury progress to the color black. S1 reported that she and R1’s family/responsible party would provide wound care to R1. According to S1, R1’s family/responsible party contacted the doctor, which resulted in a visit by a medical staff.

When interviewed on 11/5/2021 the licensee Waldi Lopez informed investigator Hector that R1 was on Palliative care with Kaiser before reported as having a pressure injury. Licensee also stated that they contacted Kaiser reported the residents decline and need for hospice care. Licensee could not provide a timeline of when these actions were taken. Licensee also indicated that R1’s responsible party would provide wound care to the resident with staff.

When interviewed on 11/12/2021 R1’s family/responsible party disclosed being aware that S1 was treating R1’s wound, however she did not witness S1 or any facility staff provide wound care and denied assisting S1 or other facility staff to provide wound care. Additionally, R1’s responsible party indicated that she had no knowledge of the extent of the injury until Kaiser began treatment.

On 12/9/2021 LPA Avetisyan conducted interview with the Kaiser Nurse Practitioner (NP) who visited R1. During the phone call the NP conducted review of R1’s medical records. While reviewing the records NP confirmed that R1 did not have an order or was receiving Palliative care prior to the 6/2/2021 home visit. R1’s records did not document communication from any individual regarding the change in R1’s condition or the pressure injury. The 6/2/2021 visit was a Semi-Annual visit and was not conducted due to a requested follow up.

Information obtained during the course of the investigation revealed that the licensee/ administrator /staff neglected to address the change in R1’s condition by failing to notify R1’s physician when the pressure injury developed. Additionally, Staff 1 who is not a skilled medical professional provided improper care to the pressure injury resulting in the pressure injury worsening and being documented as Unstageable on 6/2/2021 therefore the allegation is Substantiated at this time. Exit interview conducted, with staff and copy of report, citations, civil penalties and appeal rights emailed to info@trudezhomecare.com