Complaint Investigation Report

Care records and interviews of facility staff and outside sources showed that R1 had had Alzheimer’s Disease, was incontinent, wheelchair-bound, and required a hoyer-lift machine with caregiver assistance to transfer both in and out of bed, and in and out of wheelchair. According to R1’s hospice agency written care plan, there was an instruction for R1 to be “up to recliner 2 times a day [effective] 05/18/2022.” However, the electronic time and date-stamped nature of the hospice care plan showed that said instruction was not transcribed/written into R1’s hospice agency care plan until 07/01/2022 (the date the complaint was filed). Per the hospice agency’s electronic time and date-stamped progress notes: During April 2022, R1’s hospice care plan described “turning [them] every few hours in bed” to prevent skin breakdown. The recliner topic came to relevance after R1's responsible person expressed concern that R1 might be socially isolated if they were put back to bed (inside their bedroom away from their housemates) during portions of the day.

Interviews of facility staff and hospice staff, corroborated by hospice progress notes, showed: During May 2022 through end of June 2022, R1’s hospice nurse gave repeated verbal instruction to facility staff to help R1 transfer from their wheelchair to the recliner during the day so that R1’s skin could get some relief from pressure. During this same period, facility caregivers and a manager repeatedly conveyed to the hospice agency their concern that R1’s body had become increasingly "stiff," and that transferring R1 to the recliner would negatively impact their skin instead of helping it. Facility staff expressed that they preferred to transfer R1 to bed, where R1 could be more comfortably transferred and more effectively rotated in bed. [According to the Mayo Clinic’s encyclopedic chapter on “Bedsores (pressure ulcers)”: “Friction occurs when skin rubs against clothing or bedding…and can make fragile skin more vulnerable to injury…and shear occurs when two surfaces move in the opposite direction.”] Due to R1's baseline cognitive impairment, they were unable to be interviewed by CCLD about their own care preferences.

Over multiple unannounced site visits to the facility during July 2022: LPA observed facility staff use the reclining feature of R1’s wheelchair to help redistribute pressure on their body. LPA also observed facility staff use a hoyer-lift machine to transfer R1 from wheelchair to bed after lunchtime, so that their skin could get rest from pressure. Regulation requires RCFE licensees to “ensure that the hospice care plan is current, and accurately matches the services being provided, and that the [resident’s] care needs are being met at all times.” Although Licensee’s staff did not follow hospice’s specific instruction for recliner-use for R1, Licensee also timely and repeatedly communicated their reasonable basis for not doing so to both R1’s hospice team and responsible person. [CONTINUED ON LIC 9099-C, 2 of 4]