Complaint Investigation Report

Staff took C1 to the outpatient wound care clinic after the 3 week period on Wednesdays, and home health came to the facility Monday and Friday for wound care.

LPA reviewed documentation from the wound care clinic visits. Documentation from 2/22/23 indicates C1 had a “pressure wound to coccyx.” Records indicate the wound at the beginning of the visit was a Stage 2 pressure injury that was not healed. The 2/22/23 records indicate a physician debrided the wound, and in post debridement the wound was a Stage 3 pressure injury.

LPA reviewed documentation from the 3/1/23 wound care clinic visit. The records indicate at the beginning of the visit, the wound was a Stage 2 pressure injury, a physician debrided the wound, and post debridement the wound was a Stage 3 pressure injury.

LPA reviewed documentation from the 3/8/23 wound care clinic visit. The records indicate at the beginning of the visit, the wound was a Stage 2 pressure injury, a physician debrided the wound, and post debridement the wound was a Stage 3 pressure injury.

Administrator stated on 3/23/23 that C1 saw the wound care physician on 3/22/23 and the physician felt the facility could care for the wound. On 3/23/23, C1 saw their Primary Care Physician (PCP), who confirmed the pressure injury was a Stage 3 sacral wound.

Based on the information obtained, the allegation is deemed substantiated at this time.

Exit interview, deficiency cited on 9099-D, report given, appeal rights given.