Complaint Investigation Report

At the time of the complaint allegation, R1 was being followed by a visiting nurse practitioner (NP), who operated as an extension of R1’s primary care physician (PCP), to help address R1’s health issues as they developed. Available care records on R1 and interviews of staff and outside sources aligned to show that R1 was memory-impaired, wheelchair-bound, wore incontinence briefs, and required staff assistance with mobility, transferring, and incontinence care, among other tasks.

According to interviews of Licensees/managers, facility caregivers usually checked residents’ briefs at least once every two (2) hours, changing them if they are wet or soiled. However, Licensees/managers also acknowledged that the overnight staff (who are alone on duty) were allowed to themselves nap in between their incontinence check rounds, and that there was typically a period from around “10:30 AM or 11:00 PM” to around “4:00 AM to 5:00 AM” daily when the overnight staff were not checking on residents. Caregiver interviews varied slightly, but they generally corroborated that there was usually a window of between four (4) to six hours (6) during the overnight shift when R1’s briefs were not being checked and changed.

LPA obtained multiple photographs from multiple sources, which together showed: On 08-02-2024, the skin on the area in question on R1’s buttock was closed/intact. On 08-30-2024, the top layer of skin over this same spot was broken, indicating a pressure injury had developed on R1’s buttock. There was also a small black scab inside the broken skin area.

LPA also obtained a photograph, which showed during the morning of 07-26-2024, staff did not provide timely needed incontinence care to R1, as evidenced by R1’s bedsheet/mattress being visibly wet with urine (the wet spot was 4 feet by 1 foot) where R1’s back would have been. Interviews of 2 of 2 staff showed that R1 had been wearing an incontinence brief at the time they discovered them in this condition.

Medical records and outside source interviews showed on 08-30-2024, R1’s PCP gave a telephone order (which R1’s NP transcribed into writing for facility staff), instructing them to perform the following interventions: Reposition/rotate R1’s body weight when in bed every two (2) hours, change R1’s incontinence briefs as soon as it is soiled, and apply Calmoseptine and Vitamin A&D ointments to R1’s buttocks.