Complaint Investigation Report

LPA reviewed the hospice care reports for R1 dated between April 25, 2025, to May 28, 2025, which stated that on April 25, 2025, R1 has a diagnosis of senile degeneration of the brain, dysphagia, unspecified dementia, chondromalacia patellae in left and right knee, hypothyroidism, heart disease, chronic pain syndrome, essential hypertension, hyperlipemia, gastroesophageal reflux disease without esophagitis, chronic kidney disease, weakness, depression, and generalized anxiety disorder. A skin assessment was done on R1 upon admission on April 25, 2025, in which R1’s skin was normal and intact. R1 was a high risk for pressure ulcers. Per the hospice report dated April 26, 2025, R1 continues to be at high risk for pressure injuries due to immobility and chronic pain. Staff were advised to reposition R1 every two hours to maintain skin integrity, and that staff verbalized understanding of the instructions and to participate actively in R1’s plan of care. Per hospice report dated May 9, 2025, R1 had developed stage 2 pressure sore on her coccyx. The hospice reports further details that wound care treatment was done during the visit and that wound care services for R1 were requested. On May 12, 2025, wound care treatment was done on R1 and staff were advised to continue turning R1 every two hours for wound care prevention and worsening of the wound. On May 23, 2025, R1 continued to develop a stage 2 pressure sore on her coccyx and staff were reinforced to reposition R1 every two to three hours on her sides to off-load pressure on her coccyx. Staff verbalized understanding of the instructions. Hospice care report dated May 28, 2025, a Foley catheter was inserted in R1 for wound management. LPA reviewed the wound care specialist reports for R1 dated between May 12, 2025, and May 27, 2025, which stated that R1 has a pressure induced deep tissue damage of left heel and an unstageable pressure ulcer of sacral region.

LPA conducted interviews with four (4) witnesses from R1’s hospice agency. Witness #1 (W1), who admitted R1 was under hospice agency on April 25 and April 26, 2025. W1 confirmed that upon R1 admission, a skin assessment was done on R1 in which R1’s skin was normal, did not have any redness or open wounds. W1 confirmed that R1 was a high risk for pressure ulcers due to R1’s immobility and diagnoses. Four out of four witnesses interviewed confirmed that during hospice visits, orders were given to facility staff to reposition R1 every 2-3 hours to maintain skin integrity and facility staff on duty verbalized to hospice nurse's that they understood the instructions to reposition R1 every 2-3 hours. LPA interviewed five facility staff who were involved in R1’s care between April 25 and May 29, 2025. Five out of five staff confirmed that R1 was not being repositioned every 2-3 hours since April 25, 2025. LPA reviewed the facility’s R1 turning chart records that shows the facility only documented R1 being repositioned on May 28 and May 29, 2025.