Complaint Investigation Report

R1’s service plan also indicates they used a hospital bed with low air loss mattress to relieve pressure. The service plan indicates R1 is prone to pressure injuries due to sitting a lot and asks staff to rotate R1 as much as possible every shift and to keep bedding clean and dry. The service plan also indicates R1 wears special boots/braces to try to prevent pressure injuries on the heels and legs.

On 6/4/21 starting at 2:22 pm interviews were conducted with staff and residents. Interview with staff revealed that they would reposition R1 every 2 hours, but do not document the repositioning. R1 was also regularly seen by a home health nurse and received physical therapy, hence R1 was consistently observed and monitored by appropriately skilled professionals.

Records revealed that on 4/29/21 R1 was observed by Home Health Agency (HHA) nurse to have a stage 2 pressure injury on the sacral coccyx. Charting notes from 5/13/21 indicated that R1’s left buttocks was red and tender, and the nurse provided wound care treated. On 5/14/21, chart notes indicate HHA nurse instructed the staff to apply barrier cream at every brief change but to not apply gauze or a patch and leave it open. Per the HHA notes, there was no indication of neglect on behalf of staff. A review of HHA notes did not indicate that the wound appeared above a stage 2 pressure injury. HHA notes for 5/21/21 state R1 has a small sacral excoriation and informed staff to continue to use barrier cream at each diaper change.

Simultaneously, chart notes on 5/15/21 indicate R1’s catheter continued to have leaking around the stoma/insertion point and notes to clean as needed to prevent breakdown. Between 5/15/2021 – 6/1/2021, due to frequent HH visits, R1’s catheter was regularly monitored. The 6/1/21 chart notes at 6:05pm indicated the HHA nurse changed the catheter and noted the catheter continues to leak around the surface area when flushing and in use by R1. According to the chart notes, the HHA nurse indicted they would notify the home health charge nurse to recommend R1 be seen by their primary care physician to address the ongoing issue of the catheter leaking. HHA notes from 6/1/21 indicate the catheter continues to drain around the tube and not through the tube. HHA notes state the recommendation for facility staff is to send out R1 for treatment if unstageable and the suprapubic catheter is not functioning properly and is draining around tubing not through. Hence, R1 was sent to the hospital on 6/1/21 due to foley catheter malfunction and returned to the facility the same day with special instructions recommending a wound care specialist.