Complaint Investigation Report

2. Staff did not prevent resident from developing multiple pressure injuries while in care.

It is alleged that the resident (R1) developed unstageable pressure injuries on their mid back, left heal, scapula, right thigh sacral area, and a deep tissue injury on the right heel while residing at the facility. LPA Urena interviewed the R1’s Representative (R), and the interview revealed that R1 had a pressure wound above the coccyx area when R1 was admitted to the facility. R reported that R1 stopped eating and drinking before December 2024 and had lost weight but did not say how much weight. R was dissatisfied with the care facility staff were providing to R1 such as not brushing R1’s teeth, not celebrating “anything”, not allowing them to see when facility staff changed R1’s diapers. Furthermore, the R reported that R1 was receiving Home Health services for the pressure wound. No other reports of pressure injuries were reported by the R during the interview.

Interview with the Administrator revealed that R1 was admitted to the facility on 07/31/2024 with significant skin integrity issues and a history of skin breakdown. The facility immediately implemented frequent incontinence care, repositioning, hygiene assistance, and monitoring, while Home Health (HH) services were involved for wound assessment and ongoing care starting on 08/01/2024. The HH nurse visited the facility twice daily to monitor R1’s medical condition, perform body assessments, monitor skin integrity, and provide wound care follow-up and recommendations to facility staff. Interview with staff revealed that they were following HH nurse’s instructions on how to care for R1’s skin, by repositioning R1 in bed and using supporting pillows. Interview with the HH nurse revealed that R1 was admitted to the facility on 07/31/2024 with pressure wounds at Stage1 and Stage 2, and HH began proving services to R1 at the facility on 08/01/2024. Per HH nurse, facility staff followed all instructions for wound care, observed that the wound dressings were always clean, and observed staff to be caring when taking care of R1. HH nurse reported that R1 was hospitalized in September of 2024 for a UTI, and when R1 returned to the facility, R1’s skin breakdown was in worse condition. Furthermore, HH nurse reported that R1’s wound condition would fluctuate due to being bedbound. HH continued services for R1 until 02/03/2025, when R1 was admitted to the hospital.