Complaint Investigation Report

A review of home health services records was conducted. An assessment document dated 08/23/2021 revealed the reason for the assessment was for discharge from agency. The certification period was from 06/25/2021 to 08/23/2021 and the date the assessment was completed was on 08/19/2021. Under the Integumentary status heading, the question on whether R1 had at least one unhealed pressure ulcer at State II or higher or designated as unstageable was entered as no. The assessment allows the user to enter the number of unhealed pressure ulcers at each stage and nothing was entered. Further, the number of current Stage I pressure ulcers was listed as zero. A note reads “Patient has no pressure ulcers or no stageable pressure ulcers.” The discharge da te is listed as 08/19/2021.

R1 was interviewed where it was revealed R1 was unable to reposition in bed. R1 had a call button where they could call for staff assistance. Interview revealed R1 would be repositioned in bed one time in the morning and sometimes when staff would come to change R1. It was further revealed caregivers would clean R1’s sores put medication on them. The interview revealed R1 was not repositioned frequently. The facility was not able to provide documentation to show how frequently R1 was repositioned by staff.

Hospital records were reviewed. The Patient Education & Visit Summary revealed R1 was seen on 08/27/2021 for bleeding from the coccyx. Discharge notes read follow up with Primary Care Provider (PCP) is needed. Staff interview revealed that a review of hospital discharge paperwork is usually done along with contact with PCP for wound assessment. According to information revealed in the interview, it did not look like the review and contact with PCP was done.

A staff interview revealed a new care plan is developed when pressure injuries are documented. Based on interviews, the facility did not obtain an updated Physician’s Report nor did they update R1’s care plan. Facility Charting Notes revealed seven (7) notes relevant to this investigation. On 08/27/2021, it noted R1 had just returned from the hospital with a dressing in place on the buttocks. On 09/01/2021, it noted the wound on the buttocks did not have a dressing when changing R1. Brief had blood on it. Staff changed and repositioned R1 and left pendent within reach. Staff would continue to monitor. On 09/15/2021 at 1:53am, it was noted that staff responded to a pendant call and found R1 sitting on the floor.