Complaint Investigation Report

On February 5, 2025, R1 developed a wound on their left hip and on the heels of their feet. R1 received Home Health services through Kaiser Permanente for catheter care and heel wounds. On February 5, 2025, R1 was transported to Kaiser Hospital due to a ruptured urethra and for further evaluation of the hip and heel wounds. R1 returned to the community on February 6, 2025, after hospital treatment with a diagnosis of Urinary Tract Infection and orders for medication treatment. Four days later, on February 10, 2025, the Health Care Director requested R1 be sent out to Kaiser Hospital for further medical evaluation for the hip and heel wounds that were not improving. Resident was treated and admitted to the hospital and was discharged on February 18, 2025, to a Skilled Nursing Facility.

During the course of treatment the Power of Attorney (POA) received communication from both facility staff and Home Health regarding the hip and heel pressure wounds. Facility had spoken to the Power of Attorney (POA) on January 29, 2025, requesting the resident receive hospice care for the open wounds in order for the resident to return to the facility. POA declined hospice services due to a scheduled surgery for kidney stones. The physician was notified and the nurse treated the affected area. POA was aware of R1’s declining health and management discussed with POA to consider a personal caregiver to provide supervision to prevent further falls or injuries but family was not able to provide a personal caregiver. Care staff would do frequent body checks and rotate R1, based on R1’s service plan, which was documented by facility staff and Home Health.

Due to statements and documents, nurses’ progress notes and home health notes there is not enough information to support the allegation that Resident #1 sustained stage 4 pressure injury while in care due to Neglect/Lack of Care and Supervision. The allegation is Unsubstantiated.

It was alleged that Resident sustained a fracture while in care due to lack of care and supervision. Resident #1 (R1) had eleven unwitnessed falls in 2023-2024 in their bedroom; due to R1 getting out of bed and walking. Per Physician’s Report dated October 31, 2024, R1 is unable to transfer to and from the bed and is non-ambulatory. R1 also is diagnosed with Mild Cognitive Impairment.