Complaint Investigation Report

All areas of skin on R1 were closed. Interviews with facility caregivers and managers unanimously corroborated that while there was some rash R1’s bottom at time of move in, there were no actual open areas of skin.

Staff and outside interviews, and R1’s LIC602 Physician’s Report, corroborate that R1 was incontinent and wheelchair dependent. According to R1’s Hospice Plan of Care, R1 needed to be turned and repositioned in bed every 2 hours, and hospice nurses educated facility staff on the importance of preventing skin breakdown as opposed to wound treatment. Records and interviews revealed R1 was discharged from Hospice on April 2, 2020, and began services with a Home Health Agency (HHA) on April 3, 2020. Record review from the HHA, noted that between April 4, 2020, and April 9, 2020, four different HH staff documented that they provided facility staff education on how to maintain R1’s skin integrity. On April 9, 2020, HHA staff instructed facility staff to implement a turning schedule which restricted R1’s time in one position for 2 hours or less as R1 was restricted to bed. They also instructed staff to float R1’s heels off their bed surface at all times. Interviews with direct care staff revealed staff knew R1 needed to be rotated/repositioned when in bed, but no staff provided that they knew R1’s heels needed to be floated above the bed surface. Although R1’s HHA instructed R1 needed to be repositioned/rotated in bed every 2 hours or less, interviews of R1’s actual caregivers showed while R1 was in bed staff stated they turned R1 every 2-3 hours, and twice during the night. None of the staff stated they floated R1’s heels above the bed surface. Review of facility records revealed the licensee was unable to produce a Needs and Services Plan / Care Plan for R1.