Complaint Investigation Report

Relevant party reported to the Department that resident (R1) allegedly sustained multiple pressure injuries due to staff neglect and was sent to the hospital regarding injuries on December 2, 2024. R1 was admitted to the facility on January 30, 2022, and had the following medical diagnoses: Diabetes Type 2, Hypertension, Atrial Fibrillation, Coronary Artery Disease, Chronic Kidney Disease, and Peripheral Vascular Disease. Per Physician’s Report (LIC 602A) dated March 8, 2024, R1’s ambulatory status was categorized as bedridden due to bilateral lower extremity weakness/paralysis unknown etiology. R1’s physical health status was marked as poor. R1 was noted to be incontinent of bowel and bladder function and required continuous bed care for potential skin breakdown. R1 was noted to be able to follow instructions and communicate their needs. R1 was noted to be unable to bathe and groom themself due to poor motor ability and weakness to bilateral lower extremities.

Based on records reviewed, R1 had a history of refusing incontinence care and repositioning from time to time, including documentation by R1’s primary care physician. It was documented that refusal of incontinence care and repositioning increased after R1 was served a 30-day Notice to Terminate Tenancy due to a change in condition regarding R1’s ambulatory status on October 15, 2024. Care notes at the facility indicated that R1 was not compliant with their dietary restrictions. Care notes also indicated that R1 received an Alternating Pressure Pad/Pump mattress overlay to assist with skin breakdown and received Calmoseptine with change of briefs. Staff reported that R1 refused medication at times. Most of the care notes are regarding R1 refusing to reposition in bed or receive assistance with incontinence care. There were several notes regarding staff trying to convince R1 to go to the ER to have skin evaluated, including November 15, 2024, November 19, 2024, November 26, 2024, November 29, 2024, and November 30, 2024.

R1 received assistance from Home Health starting November 21, 2024. Home Health included skilled nurse visits once a week and two (2) as needed visits. R1 had a wound assessment completed on November 21, 2024, indicating that R1 had two (2) Stage 1 wounds to their lower buttock. Treatment included cleaning and applying Calmoseptine. Home Health noted no changes to pressure injuries on November 26, 2024.