Complaint Investigation Report

On 05/07/2024, LPAs Esther Cortez and Sandra Urena conducted an inspection at the facility and conducted interviews and observed resident rooms between 10:00 AM and 4:30 PM. On 06/17/2024, LPA Cortez conducted a subsequent visit, conducted a record review and staff interview. During today's visit LPA Cortez conducted staff interviews and obtained pertinent documents.

On 06/19/2023, the Department received a complaint alleging Resident #1 (R1) sustained pressure injuries due to staff neglect. The reporting parties concern is that R1 developed a stage III pressure injury at the facility prior to receiving hospice care.

According to the facility file documents reviewed, R1 was admitted to the facility on 01/25/2020. Per the facility preplacement appraisal, R1 used a walker/wheelchair and required assistance for transferring, bathing, toileting, and medication management. Per the Physician’s report, dated 01/20/2020, R1 did not have a history of skin condition or breakdown. Per the Physician's report, dated 11/24/2020, R1 had listed diagnoses of congestive heart failure, muscle weakness, hypertension, low back pain and hypothyroidism. R1 was on a low-sodium diet, had bowel and bladder impairment, and required assistance for all activities of daily living, except feeding self and did not have history of skin condition or breakdown.

Based on the review of the Milestone semiannual assessment, dated 07/09/2021, R1 required one (1) person or standby assist 8x daily, required staff assistance with showers 2x weekly, required frequent incontinence assist 3x weekly, under medication management required skin treatment 2x daily, and required coordination of care with Home Health 1x weekly. Per the Service Agreement, dated 07/09/2021, effective 01/21/2020 R1 required bathing assist twice a week every Monday and Friday, and assistance with dressing daily; effective 04/21/2020, R1 required LVN to assess skin weekly to monitor skin integrity and progress, Divine Home Health to provide wound care to affected area on Mondays, Wednesdays, and Fridays, LVN/Med Tech to provide skin treatment am and pm as per MD orders, and caregivers were to provide R1 with assistance with transfers through the day; effective 07/09/2021 R1 required staff assist with toileting throughout the NOC hours, staff to check frequently to ensure R1 is clean and dry, and R1 required assistance by staff to toilet throughout the day and overnight hours.

Report will continue on LIC9099-C (3RD PAGE).