Complaint Investigation Report

During an interview with Executive Director Ray Pellicer, caregivers are instructed to notify med tech if they observe any skin concerns. Med techs report to the Memory Care Director Ira Lustina, and Ira will contact the doctor and family.

When Memory Care Director Lustina was asked about facilities protocol when it comes to pressure injuries, she said, Med techs will report to me… if it’s a stage one hospice will provide a skin barrier cream or ointment. If it’s stage two, hospice will come and treat the wound. If the residents on Home Health, they will come treat it as well. If it’s unstageable, we send them out. We report it to the doctor first then they will order for us to send them to the hospital or skilled nursing. We’re not allowed to treat or stage a pressure wound so we report it to the doctor first.

Document review was consistent with the information gathered during interviews. The care team would reposition residents who had pressure wounds, document the time the resident was repositioned and make additional notes regarding status or condition of the resident (what side they are laying on). The documentation was consistent and it was documented the same over an extended period of time. The documentation style was consistent and followed a pattern that was used by all different staff, and used on all different residents, Residents 1 (R1), Resident 2 (R2), and Resident 3 (R3). All three residents were on hospice and were receiving wound care.

Regarding the allegation: Facility staff did not notify residents family about pressure injuries

During the investigation 0 of 17 individuals provided any information or evidence that supports the complaint allegation. Based on interviews, record review, and due to the lack of information provided when the complaint was filed, much of the information gather contradicts the complaint allegation.

During the investigation all five staff members who were asked about the allegation provided a consistent response and it was clear the staff understood their responsibility and know how to respond to pressure injuries appropriately. When the executive director was asked how staff are trained to respond to pressure wounds, executive director stated, the med tecs will report to Memory Care Director, and [The Memory Care Director] will call the doctor, family, and get a treatment order.