Complaint Investigation Report

Family was not notified of residents’ pressure ulcer – SUBSTANTIATED

LPA review of documents revealed that starting on 02/09/2022 R1 was being treated in the facility by home health for a stage 2 pressure injury. Various text messages received between 02/05/2022 – 02/07/2022 confirmed that the family was aware that R1 had an on-going spot that was visible during R1’s admission to the facility. On 02/05/2022 the family was notified that the spot opened up and the facility had been treating it for 1 week. At this time family stated they thought the facility would inform them if they were treating R1 for a pressure injury.

During staff interviews it was learned that when R1 moved into the facility they already had the pressure injury and the family was aware of it.

House manager stated R1’s family member was present in the bathroom when the facility did R1's physical assessment. When R1 moved in R1 had a wound on their hip that had a band aid on it. The family supplied a cream to put on the wound. The wound healed and came back a few times. The family took R1 back to see their doctor in February 2022 and home health was ordered for R1. Administrator texted the family and notified the wound was getting bad again and was not healing. The family said, “I wish you would have told me sooner.”

It was determined that although the family was aware that R1 had an ongoing issue with the pressure wound, the family was not notified in a timely manner that the wound had opened up until 1 week after discovery by the facility therefore the allegation is substantiated.