Complaint·March 8, 2023

Regarding the allegation: Resident sustained unstageable pressure injuries while in care The investigation revealed that prior to being admitted to this facility on 06/28/2021, R1 was in a skilled nursing facility (SNF) for rehabilitation from surgery from 6/15/2021-6/27/2021. Medical records claimed that R1 had the chronic conditions of hypertension, prostate cancer, chronic lower extremity edema, hemorrhoids and lower gastrointestinal bleeding, and a deep vein thrombosis in the left leg, in which R1 underwent surgery to treat in June 2021. Discharge summary paperwork from the SNF from 06/27/2021 documented that R1 had discoloration on the left arm, lower level edema and discoloration, right arm discoloration and a surgical incision on the left leg. Facility records also noted that on 06/29/2021, R1 was observed with having ‘dry sores’ on R1’s coccyx area, but there was no indication that they were pressure injuries. On 7/07/2021, R1 was observed with an open wound on the side of their buttocks. Thereafter, R1 was admitted to home health for wound care. The LPA also observed home health notes from the start of R1’s admission to the facility, in which R1 received wound care, occupational therapy, and physical therapy. A review of R1’s medical history indicated that R1 had a history of skin integrity issues and hospital admissions. R1 was admitted to the hospital on the following dates due to rectal bleeding and lower leg edema: 7/14/2021, 10/16/2021, and 2/6/2022, and 3/28/2022. The LPA reviewed a home health Plan of Care with a start date of 03/28/2022, with the admitting diagnosis of hemorrhage of anus and rectum. R1 was documented as having bilateral buttocks and upper thighs incontinent dermatitis. According to the Mayo Clinic, dermatitis is a general term to describe skin irritation that can cause the skin to blister, ooze, crust, or flake off. R1 was seen weekly by a home health nurse, and a review of visit notes indicated that the nurse did not indicate the presence of pressure injuries. Home health documented R1’s condition as dermatitis during the following nursing visits: 3/28/2022, 4/06/2022, 4/13/2022, 4/18/2022. Notably, on 4/27/2022, a home health nurse noted that R1’s dermatitis was worsening yet did not make mention of any pressure injuries. Medical records indicated that R1 was admitted to the hospital 4/26/2022 for mild leg pain and severe swelling, and again on 4/30/2022 with the admitting diagnosis of chronic cellulitis. However, home health continued to observe R1 weekly and did not observe evidence of pressure injuries on the following dates: 5/04/2022, 5/11/2022, 5/16/2022, 6/1/2022, and 6/10/2022. Notably, on 06/10/2022, facility charting notes indicated that R1 did not allow the home health nurse to provide care to R1’s bottom. Information obtained from staff interviews revealed that R1 would oftentimes refuse care from the staff. Staff also stated that R1 sat in their recliner and refused to lay in their bed. This observation was also noted by R1’s physician and home health nurse, and was commented in the interview conducted with R1’s family member. As a result, staff stated they would encourage and assist R1 with standing up and moving around to alleviate pressure to R1’s buttocks. Staff also commented that R1 did not leave their room for meals nor activities and said that R1 primarily stayed in their room. R1 was also receiving physical therapy (PT) twice a week from 4/4/2022 – 5/25/2022 to improve mobility and functioning and to manage R1’s pain. A review of PT notes revealed that R1 would participate in PT and completed exercises as requested. Although it was sparingly documented in PT notes that R1 would refuse care, staff admitted that R1 would regularly refuse to participate in PT due to pain. Facility charting notes indicated that R1 was regularly assisted with the self-administration of pain medication as prescribed by their physician. On 06/11/2022, R1 was hospitalized due to lower extremity edema and right foot redness with drainage. Hospital records noted that R1 had ‘chronic venous stasis dermatitis bilaterally, with superimposed erythematous rash’ and a ‘sacral pressure ulcer with associated open lesions’. Hospital records did not indicate the staging of the wound on R1's sacral region. R1 was discharged from the hospital on 06/16/2022. On 06/17/2022, R1 was seen by a home health nurse, and it was documented that R1 had a stage 2 pressure injury on the left posterior heel (3x3x0cm) and dermatitis on the bilateral buttocks and posterior thighs. Home health began seeing R1 three times a week for wound care; however, home health did not document the presence of any additional wounds on the following visit dates: 6/18/2022, 6/20/2022, 6/22/2022, 6/24/2022. Hospital and facility records indicated that R1 was hospitalized on 06/26/2022 with the chief complaint of rectal bleeding. Facility records indicated that R1 was unable to stand and bear weight and was experiencing pain. Whereas R1 was discharged back to the facility on 06/27/2022, records and interviews confirmed that R1 was sent back to the hospital for skilled nursing placement, as the facility claimed that R1 required a higher level of care due to the staging of the wounds. Per medical records review, hospital staff staged R1’s pressure injury on the sacral/buttocks as unstageable, a pressure injury of the left lower leg as an unspecified stage, and pressure injury of the right lower leg between a stage 3 or stage 4. Interviews with R1’s family member confirmed that the facility sent R1 back to the hospital once they discovered the staging of the wounds and communicated that R1 required a higher level of care. Records review and interviews confirmed that R1’s wounds were regularly observed and treated by home health, and home health did not stage R1’s wound above a stage two when R1 resided at this facility. Once the facility received documentation that wounds had progressed above a stage 2 pressure injury, the facility noted that R1 needed a higher level of care and R1 was sent to the emergency room. Based on the information provided, there is insufficient evidence to support the claim that due to neglect, R1 sustained unstageable pressure injuries while in care. R1’s condition was regularly observed and assessed by appropriately skilled professionals while residing at this facility. The investigation did not reveal any suspicion of neglect or lack of care from home health or hospital staff. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff did not meet resident's hygiene needs It was alleged that staff failed to meet R1’s hygiene needs. It was alleged that on 06/27/2022, R1 had to wait an extended period of time to receive assistance with tending to their toileting and hygiene needs. It was allegedly one of the ‘first times’ that R1 had to wait an extended period of time. Staff interviews revealed that residents are checked on at least every two hours to ensure that incontinent needs are met timely. Interviews revealed that staff are responsive in meeting the toileting needs of the residents and are communicative with one another if they need assistance with changing or refreshing a resident. Records review indicated when R1 was unable to ambulate with a walker to the restroom, staff would assist with changing R1’s pull-ups. In general, staff indicated that R1 was compliant when requiring assistance with changing and toileting. Staff admitted that R1 would experience pain and occasionally would refuse to be changed. However, staff indicated that they would inform the other staff on the floor to ensure that they checked on R1, or would check on R1 at a later time to ensure their hygiene needs were met. A review of home health and physical therapy notes did not indicate that R1 appeared soiled during the visits. Interviews with R1’s responsible party supported claims that they would visit R1 weekly, and did not observe R1 to be soiled or having to wait an extended period of time for care. Information obtained from an interview with R1 stated that although staff sometimes were not ‘quick’ to assist R1, R1 claimed that when R1 had been soiled, staff would assist them. Lastly, interviews revealed that residents are regularly checked for skin breakdown or the presence of wounds. Based on the information obtained, there is insufficient evidence to support the claim that the staff did not meet the resident’s hygiene needs. Despite being checked and refreshed within a two-hour time frame, R1 - or any resident - can soil their clothing soon after being checked. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.