Complaint Investigation Report

R1 was receiving home health services which was to address and monitor R1’s wounds. On or about 08/14/2023, R1’s home health agency was changed by R1’s responsible party. Progress notes on 08/12/2023, notated R1 primary diagnosis to be an unstageable pressure injury on R1’s right hip and an unstageable pressure injury on R1’s sacral region.

On 08/14/2023, staff were informed by home health during a visit to the facility that R1 had two pressure injuries, as noted during routine assessment, one on the sacrum and one on the right hip. Both pressure injuries were unstageable. Despite the severity of these wounds and the immediate need for medical intervention, staff delayed seeking evaluation by a medical professional, such as a doctor, for approximately 17 days. This delay in obtaining timely medical attention directly contributed to the worsening of the R1’s condition and constitutes negligence on the part of the facility. According to one staff interview, staff failed to adhere to the prescribed turning and repositioning as described during a former staff member’s interview. Through interviews and record reviews, facility did not provide appropriate intervention following the discovery of these injuries, exacerbating the harm suffered by the resident.

On 08/16/2023, Home health nurse reached out to R1’s primary care physician who advised R1 needed to be seen in the Wound Care Clinic. On 8/31/2023, R1 was seen at Wound Care Clinic. It was noted during R1’s Wound Care Clinic appointment that R1 needed a high level of care than what they were receiving at the facility.

Facility staff were interviewed and reported home health nurse would come and change R1’s band aid. Staff indicated home health instructed staff not to touch R1’s pressure wounds or clean them when Home Health was not present. Per home health documentation, Staff were instructed to change R1’s band aid if it was soaked. Staff stated they never changed R1’s band aid. Staff explained that home health would communicate with the Licensee about the pressure injuries. Lastly, based on a staff interview, it was discovered that staff did not receive any training and experience regarding pressure injuries.