Complaint Investigation Report

The LPA advised the Licensee that the complaint has been assigned to an Investigations Branch (IB) Investigator to conduct the investigation. The LPA requested documents pertinent to the investigation.

Investigator Bendana conducted interviews on 07/28/2022 with residents, staff #1 (S1) and administrator; on 08/11/2022 and 08/12/2022 with Dignity Home Health Registered Nurse; on 08/12/2022 with R1’s Nurse Practitioner; on 09/02/2022 with R1’s Primary Care Physician; on 09/08/2022 with R1’s resident representatives; and on 09/09/2022 with Dignity Home Health Physical Therapist. Additionally, Investigator Bendana obtained and reviewed copies of R1’s Marian Regional Medical Center medical records, Dignity Home Health records, photographs of R1’s pressure injuries, death certificate, and facility records including documents relevant to R1.

The investigation revealed that on 12/15/2020, R1 was admitted to the facility under the prior facility ownership. The facility had a change of ownership effective 01/12/2022, and the current licensee /administrator, Aprilyn Soriano became the new facility owner. Documents reviewed revealed that R1 had a history of skin breakdown and was treated by home health for wound care during various times while residing at the facility.

The home health records dated 04/05/2022 through 05/27/2022, revealed that R1 was being treated twice per week for multiple pressure injuries. On various dates, the home health nurse documented R1’s pressure injuries as stage 1 and stage 2. During the visits to perform wound care, the nurse stressed the importance of continued pressure relieving measures and good nutrition and hygiene to promote healing, and when to seek medical attention if symptoms worsened.

A review of the home health clinical notes for the month of May 2022 revealed that on 05/03/2022, the home health nurse performed wound care. Upon assessment of the wound, the nurse noted R1’s depends were soiled with urine. The nurse assisted with the caregiver to clean R1 and change R1’s depends. The caregiver assisted with repositioning R1 and the nurse stressed the importance of good nutrition, of increased protein, vitamin C and fluids to promote optimal wound healing as well as pressure relieving measures.