complaint·October 31, 2023

(Cont from 9099A) Staff did not ensure resident was hydrated. It was alleged that due to severe dehydration R1’s health condition got more complicated. Staff revealed that they keep resident hydrated at all times. Between 06/23/23 and 06/25/23 R1 was having swallowing difficulties but was able to intake fluids. Staff informed hospice services and staff also spoke to R1’s responsible party, who called 911. A review of hospice records revealed that R1 ate and drank regularly. R1 was assessed for hydration during skilled nursing visits and there were no signs of dehydration. Other witnesses interviewed during investigation revealed that they saw a “two-liter bottle” of water by R1. Due to finding no evidence to suggest fluids were withheld or any actions or lack thereof by staff contributed to R1s dehydration, there is not sufficient information to support the allegation, Therefore, the above stated allegation is determined to be unsubstantiated at this time. Staff did not observe a change in resident's condition It was alleged that Staff did not observe a change in R1s condition. Interviews with staff on 06/30/23, 10/31/2023, and interviews conducted during the course of the investigation reveal that staff noticed R1’s wounds not healing. Staff revealed that as of 06/14/2023, they noticed that R1 was having swallowing difficulties and developed prohibited health conditions, posing immediate danger to R1’s health and safety. Based on interviews and records review staff monitored R1s condition and noticed changes in R1s condition consequently there is insufficient information to support the allegation. Therefore, the above stated allegation is determined to be unsubstantiated at this time. Exit interview conducted/Appeals/Copy of report given. (Cont from 9099) It was alleged that Resident sustained multiple ulcer wounds while in care. Staff interviews conducted on 08/01/2023, revealed that upon admission to the facility, staff assisting Resident #1 (R1) noticed a black bloody spot on R1’s coccyx. The spot felt hot like it was burning. Staff was repositioning and turning R1 every 2 hours. Interviews also revealed that although a “small, black spot” was noticed near R1’s coccyx, staff did not know “what was under the tissue,” but it was “deep when the skin opened on 06/13/2023”. A review of hospice/palliative and wound care records conducted by the IB investigator revealed that while in care at the facility, R1 developed pressure injuries. As of 06/13/2023, the pressure injuries were staged as Stage 4. Although R1 was receiving wound care by medical professionals between 06/13/23 to 06/25/23, the conditions of the wounds got worse. Records revealed that a sacral stage 4 pressure injury was addressed and subsequently treated by the wound specialist. However, other Stage 4 pressure injuries noted in hospice records, were not addressed by medical professionals. IB investigators review of the hospital records revealed,that on 06/27/2023, R1 was admitted to the hospital with multiple Stage 4 pressure injuries on sacrum, Stage 4 pressure injuries on the left and right buttock. R1 was diagnosed with sepsis (secondary to the buttock wound infection). In addition, R1 had several deep tissue pressure injuries. Overall, the investigation revealed that although facility staff including the Administrator had knowledge that R1’s pressure injuries were not healing, they failed to obtain all required information from the hospice agency and take appropriate measures to ensure that there is no immediate threat to the health and safety of the resident. Based on the information revealed from interviews and records review, there is sufficient information to support the above stated allegation. Therefore, the allegation is determined to be Substantiated at this time. Staff did not seek timely medical care for resident. It was alleged that R1’s overall health condition was declining, and staff failed to provide emergency medical assistance on time. Staff revealed that as of 06/14/2023, they noticed that R1 was having swallowing (Cont to 9099C) (Cont from 9099C) difficulties and developed prohibited health conditions, posing immediate danger to R1’s health and safety. Staff admitted not contacting emergency services. Between 06/14/2023 and 06/27/2023 R1’s condition got worse. R1’s responsible party was contacted, and 911 was called by R1’s responsible party. A review of the medical records verified the information received from the staff. Based on the information revealed from interviews and records review, there is sufficient information to support the above stated allegation. Therefore, the allegation is determined to be Substantiated at this time. Exit interview conducted. Appeal rights discussed. Copy of report provided.