Complaint Investigation Report

Resident #1 (R1) was sent to the hospital on February 5, 2026, and returned on February 9, 2026, with a suprapubic catheter; which was maintained by home health. R1 was admitted to hospice services and per hospice documentation, received services for pain management and comfort care. An updated medical assessment from February 9, 2026, documented R1 has a history of skin condition or breakdown.

Beginning on February 16, 2026, R1 received hospice services once a week for wound care. Per interview with facility staff, the facility requested additional wound care for a pressure injury on the sacrum; since the wound care provided to R1 was not sufficient. On February 24, 2026, R1 had an additional assessment by Wound Pros. R1 was sent out to the hospital on March 2, 2026, due to the pressure injury not healing.

R1 returned to the facility on March 5, 2026, and the facility continued to follow the Primary Care Provider’s (PCP) orders until March 8, 2026. On March 8, 2026, the Health and Wellness Director (HWD) sent R1 to the hospital since the pressure injury showed no improvement. HWD stated they did not receive hospice documentation regarding the pressure injury being stage 3 until the HWD made the decision to send the resident out on March 8, 2026. Hospice Provider Notes to the facility, dated February 26, 2026, stated the pressure injury was stage 3.

The resident did not return to the facility and resided at Kaiser Permanente until March 23, 2026. While hospitalized, it was reported the pressure injury measured 12 cm in length on the sacrum and unstageable right heel injury measured 3 cm.

LPA interviewed three of three staff members. Three of three staff denied the allegation and stated the facility continuously monitored the resident and communicated with the hospice agency to request additional wound care. Two of three staff who provided direct care to the resident stated they continued to speak with the hospice agency and felt they were unresponsive. The facility decided to send the resident out on March 8, 2026 due to insufficient wound care being provided.

LPA attempted to interview the hospice agency three different times. LPA interviewed two of three residents. Two of three residents stated they were happy with the quality of care provided and denied the allegation of neglect and lack of supervision. LPA interviewed one witness who denied the allegation that Resident developed Stage 4 pressure injury due to lack of care/supervision. The witness stated that the hospice agency was to provide wound care and that the facility was communicative and followed orders.