Inspector’s narrative
What the inspector wrote
On 5/3/21 LPA Flores interviewed residents #1,#2,#3,#4,#5,#6,#7,#8,#9,#10, #11,#12,#13,#14 (R1,R2,R3,R4,R5,R6,R7, R8,R9,R10,R11,R12,R13,R14) and staff#1,#2,#3,#4,#5,#6,#7, #8,#9,#10 (S1,S2,S3,S4,S5,S6,S7,S8,S9,S10) and requested staff in services, caregiver shift assignments, and admissions agreement, physician's report, needs and service plan/appraisal, and hospice/home health care.
T
he investigation revealed the following: Regarding allegations:
Resident(s) have developed pressure injuries while in care and Staff did not seek medical attention for resident(s) in a timely manner.
It is alleged that there are many residents with pressure ulcers at varying stages that are not being treated. During interviews with residents, 7 out of 14 residents stated not to have had any injuries recently and that facility assist residents with scheduling medical appointments. 7 out of 14 residents were unable to provide an answer due to their physical condition or cognitive skills. LPA was unable to interview R5, and R11, as residents past away prior to date of interview. 7 out of 10 staff interview stated to be able to identify pressure injuries or wounds and described the steps to take if pressure injuries or wounds are notice as follow; notify supervisor of residents' change in condition, facility then contacts either Hospice or Home health care for care, for residents that are not under hospice or home health care, facility contacts Physician to initiate proper care. 4 out of the 10 staff have not seen any residents with injures under their care. Documents review determined that 7 out 16 residents were receiving hospice services, 1 out of 7 Hospice notes reviewed noted care for altered skin <14 and care was being provided by Hospice agency, 4 out of 16 residents' documents reviewed showed residents were receiving services from a Home Health Care provider and 5 out of 16 resident documents reviewed determined residents do not receive Hospice or Home health care services. Caregiver shift assignment for the month of April reviewed showed each caregiver is assigned an average of 13 to 15 residents per day, and on days a caregiver is out, each caregiver is assigned 15 to 17 residents. Facility provided in service training to staff on the following topics and dates: Pressure Prevention on 5/18/20, Rotating Residents every 2 hours on 8/19/20, and Wound Care Prevention on 4/26/21.
Exit interview was conducted with Lori Lackey, Assistant Administrator and a copy of the report was email for signature.
