Complaint Investigation Report

Allegation: Resident developed stage 4 pressure injuries while in care

On 06/03/2024, Resident #1 (R1) moved into the facility. Prior to moving into the facility, R1 was in the hospital due to a fall that occurred at their private residence where they were found after four days. R1 was on the floor for so long, they put pressure on only one side of their body which caused all the muscles and tissues to die on that side of their body and was septic and required hospitalization.

After being discharged from the hospital, the Administrator advised R1’s Responsible Party (RP) in order for R1 to be accepted into the facility, they must be placed on hospice care and have wound specialist came to treat wounds regularly, which the RP agreed to. Administrator stated existing wounds present during admission were a wound to R1’s left iliac crest, sacrum, lower thoracic spine, left elbow as well as having multiple skin tears.

Administrator stated R1 was at the facility for less than a month and during their time there, they were seen regularly by hospice, wound care nurse and facility staff. Staff #1 (S1) and Staff #2 (S2) both stated R1 was a very aggressive resident, and they didn’t like to be touched or moved because their body was full of pain. S1 said when hospice nurses would come to bathe R1 would become combative. S2 stated facility staff rotated R1 at least every two hours and every time they would attempt to keep R1 off their wounds, R1 would roll right back onto them.

Administrator stated although wound specialist had to care for R1 wounds, facility staff had to constantly be changing R1’s bandages because they would take them off because they said they were itchy, or their bandages would get very soiled, and they had to apply fresh bandages.

On 07/01/2024, a care meeting was held regarding the status of R1s wounds, and it was agreed that R1 needs further help from medical professionals to treat R1s wounds as they were not healing. Administrator stated they notified R1s RP and concluded R1 would be sent to the hospital.

R1 was discharged less than 24 hours later from the hospital. RP took R1 back home where R1 would be cared for by family.