Complaint Investigation Report

Regarding the allegation: Failure to provide adequate care and supervision

It was alleged that upon admission to the hospital, R1 was found with multiple pressure injuries. Prior to admission to this facility, a review of R1’s medical assessment dated 9/30/2020 and R1’s discharge paperwork from the skilled nursing facility dated 10/02/2020 did not mention wounds and/or pressure injuries outside of the healing surgical wound on R1’s left hip.

The assessment conducted by home health, dated 10/3/2020 indicated that R1 had no additional pressure injuries. However, further review of the home health notes revealed that during the 10/03/2020 initial visit, staff were allegedly provided information on ‘skin and diabetic foot care’, yet additional information was not discovered as to the staging or presence of wounds. The home health visit conducted on 10/06/2020 documented that R1 had a ‘pressure ulcer/injury’ on the left heel, right heel, and coccyx with black surrounding tissue, yet there was no information regarding staging of the wounds. Intervention notes claimed that the nurse educated facility staff on the ‘diabetic precautions and management’. The final home health visit on 10/10/2020 was documented as ‘missed’; the visit notes claimed that when home health called the facility on 10/10/2020, the caregivers claimed that they did not need another ‘teaching visit’ as it related to R1’s care. Subsequently, R1 was discharged from home health services on 10/10/2020 .

The Administrator admitted that due to COVID-19, an in-person assessment was not conducted of R1 prior to R1 being admitted to the facility. Instead, the Administrator reviewed R1’s medical assessment and information from the skilled nursing facility, which neither document indicated the presence of wounds. The Administrator admitted that upon arrival to this facility, an assessment was conducted on R1 and R1 was observed to have ‘minor skin breakdowns’ on the left and right heels, and a wound on the coccyx. The Administrator was under the impression that home health would provide wound care for R1’s heels, yet the home health agency discharged R1 on 10/10/2020 and did not address the dark spots on R1’s heels. The Administrator also admitted that R1 had a ‘normal’ pressure injury on the coccyx area that was noted with redness and had started to open. The Administrator noted that R1’s heels worsened in condition, which resulted in the Administrator reaching out to R1’s primary care physician and R1’s family on approximately 10/27/2020. The Administrator reiterated that they communicated their concerns to the appropriate parties but noted that they had not received a timely response to their increasing concerns. Yet interviews with staff whom also provided care to R1 denied claims that R1 had the presence of ‘dark spots’, claimed that R1 lower body extremities were ‘good’, and appeared unaware to the fact that R1 had any wounds.