Complaint·March 14, 2025

Interview with the administrator and staff deny the allegation of R1 sustaining an unstageable injury. The following information was obtained through interviews and record review: R1 admitted 03/14/24 Hospice was initiated on or around 03/15/24. Review of the hospice care plan indicates risk for skin integrity due to immobility & Stage II pressure ulcer. Instructions to turn/reposition every two hours No indication of pressure injuries greater than a Stage II ulcer. Interviews made with hospice nurse and record review on 03/14/25 reveal nurse visits two times per week, with a doctor follow up every other week to assess the wound Interview with hospice nurse and review of care plan from 03/15/24 through 08/02/24 only indicate wound to coccyx to be Stage II pressure injury (no indication of pressure injury greater than Stage II) Interview with hospice nurse stated next scheduled visit to facility to treat and assess R1's pressure injury would have been 08/05/24, or the following Monday. According to both administrator and hospice nurse, R1's wound was never more than Stage II while under the care and supervision at the facility. Both were in communication daily regarding the status of the wound. Facility staff continued to reposition R1 every two hours through 08/04/24. Per staff, no indication the wound had progressed. On 08/04/24, during visitation, there was some indication that R1's wound may have progressed. According to both administrator, and hospice nurse, R1 was sent to the hospital for assessment. Although there is evidence that R1 had a Stage II pressure injury, Documentation and interviews with hospice nurse reveal that wound care was provided up until the Stage II pressure injury had possibly progressed. Once it was assumed that it progressed, R1 was sent to the hospital for assessment. Therefore, based on the information obtained, it could not be proven that R1 sustained a pressure injury while in care. The allegation is deemed Unsubstantiated at this time. Facility failed to comply with reporting requirements: In regards to the allegation, it was reported that R1's responsible person did not know that R1 had a wound and trusted the licensee (Board & Care) with R1's care since admission to the facility. Interview with both the administrator and hospice nurse deny the allegation, stating R1's responsible person was aware of the wound care because the responsible person signed off on the hospice care plan, and was made aware of the plan. Moreover, the responsible person is given a copy of the agreement with the hospice agency and care plan. LPA reviewed a copy of R1's hospice agreement, and observed dates and signatures by R1's responsible person, acknowledging hospice care. In addition, according to administrator, R1's responsible person is often at the facility at least once a week, and is given updates regarding R1's care. During those visits, administrator stated R1's responsible person never made any concerns or complaints regarding care and supervision provided to R1. Based on the information obtained, there wasn't enough information to corroborate the allegation of licensee failing to comply with reporting requirements. Therefore, the allegation is deemed Unsubstantiated at this time.