complaint·February 8, 2024

A complete investigation was conducted by IB Investigator, Jose Santana. During the course of the investigation, Investigator Santana interviewed the administrator, resident(s), and staff members. Investigator Santana also interviewed a hospital staff member and received hospital medical records. Regarding the allegation: Resident sustained multiple pressure injuries due to staff's negligence - It’s being alleged that a resident has multiple pressure injuries. Some of the pressure wounds were severe with dead skin tissue and were labeled as necrotic. It was reported that staff were not rotating the resident or helping the resident out of bed after the resident became bed bound. Medical records revealed the resident had multiple wounds including unstageable pressure injuries to the left medial thigh, right hip, and left hip. Hospice and a wound specialist records stated the resident received care when the resident’s pressure injuries developed. The facility and hospice records indicate the resident developed a deep tissue pressure injury to the left medial thigh around 12/17/2022 and another DTPI on the resident’s right lateral hip on 12/20/2022. Between 12/20/2022 and 12/29/2022, the wounds became unstageable. Facility records indicated on 12/30/2022, the resident developed a new unstageable pressure injury on the resident’s left hip. Facility caregivers stated they repositioned the resident every two hours. However, the hospice nurse and wound specialist believe the resident’s comorbidities may have contributed to the development and progression of the pressure injuries due to staff not repositioning the resident every two hours. The resident stated facility staff members were only repositioning the resident two times per day. IB Investigator interviewed the physical therapist on 2/28/2023 who stated that physical therapy was discontinued July, 2022 but stated the resident needed to continue physical therapy. The resident stated to the resident’s nurse practitioner that the resident was bed bound and wanted physical therapy. Facility staff denied being aware of the resident’s request. However, the facility did not ensure the resident’s physical needs were met. Due to the resident’s worsening leg contractures and increasing leg pain, the resident was unable to reposition themselves in bed. The resident experienced severe pain when caregivers attempted to reposition the resident which resulted in the resident’s refusal to be repositioned. Per Title 22 Regulations, a facility may provide care to residents who have contractures, provided that “the contractures do not severely affect functional ability and care and/or supervision is provided by an appropriately skilled professional.” A facility is also required to keep a written record of care, including documentation from a physician of the contracture’s stability, and method of intervention. The facility retained the resident despite the resident’s leg contractures that kept them from walking, failed to ensure the resident received adequate intervention while on home health services, and did not keep a written record of the limited intervention they did receive. The investigation revealed the facility contributed to the resident’s pressure injuries by not adequately addressing their contractures. The allegation that facility Neglect/Lack of Supervision contributed to the development of the resident’s pressure injuries is therefore substantiated. An immediate Civil Penalty of $500.00 is being issued today, due to the staff’s negligence. Refer to LIC 421M. At this time an Enhanced Civil Penalty (ECP) determination is pending and may be assessed at a later date. Exit interview conducted, appeal rights discussed, and a copy of the report was given.