complaint·January 23, 2024

Allegation: Resident sustained severe pressure injury due to staff neglect: The complaint alleges that Resident #1 (R1) sustained a severe pressure injury while residing at the facility due to staff neglecting R1’s needs. Interview revealed that R1 was admitted to the facility on 12/23/2023, following a brief stay at a Skilled Nursing Facility. Record review revealed that R1 had a sacral pressure injury prior to moving into the facility. R1’s physician’s report dated 12/22/2023 is marked “yes” under history of skin condition or breakdown, with the comment “sacral unstageable wound.” Physician’s report also indicates that R1 is receiving hospice care upon discharge from the skilled nursing facility. R1’s Appraisal Needs and Service Plan also indicates R1 is “currently receiving care through hospice agency” and indicates that R1 has a “unstageable pressure ulcer on sacrum and redness to right hip and buttocks area.” LPA reviewed R1’s hospice documents, which indicate R1 was receiving wound care three times per week while at the facility. Additional documentation reviewed indicates facility staff attempted to reposition R1 every two (2) hours even throughout the night. However, sometimes R1 refused and staff documented the refusal. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “resident sustained severe pressure injury due to staff neglect” is deemed UNSUBSTANTIATED at this time. Allegation: Facility staff did not meet resident’s incontinence needs: The complaint alleges that R1 was left lying in urine for 12-14 hours all night. Physician’s report indicates R1 had a “right side nephrostomy tube attached to drainage bag” to output R1’s urine, due to urinary retention. As R1 was admitted to hospice, effective 12/22/2023, prior to moving into the facility, interview revealed that hospice nurses were responsible for the care of R1’s nephrostomy tube/bag. Additionally, a staff interview revealed that prior to the complaint, R1 had multiple loose bowel movements, requiring additional incontinence care. Documentation reviewed revealed that R1 was changed additional times, due to the loose bowel movements. Staff interviewed indicated incontinent residents are checked every two hours throughout the day, as well as upon the residents’ request. LPA observed that each resident has a bell in their room to ring for additional assistance. Resident interviews revealed that their incontinence needs are regularly met and residents can call for additional assistance any time of the day or night. Staff conduct rounds during the overnight shift and rest in a common area where they can quickly respond to residents’ calls for assistance. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “facility staff did not meet resident’s incontinence needs” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.