complaint·November 16, 2022

Regarding Allegation #1 : this investigation revealed that Resident #1’s medical records from the hospital, home health agency, hospice care, and facility showed all three (3) agencies in communication with one another about Resident #1’s condition. Various medical records from six (6) different agencies [(three (3) home care services, two (2) offices of assigned doctors, and one (1) hospital)], listed the constant communication with Resident #1’s family (Daughter/Power of Attorney), facility staff, and assigned primary care physician. IB Investigator Edward Hector noted that medical records documented that Resident #1 had developed three (3) non-pressure wounds on the left, lower leg and received daily wound care by home health nurses. Prior to receiving care for the left leg wounds, Resident #1 had recently been discharged from home health services for a healed wound on the resident's right leg. Resident #1 was admitted to the hospital on 05/14/20 for poor circulation that caused open wounds. While the resident was in the hospital, the resident's physician warned the resident's family (Daughter/Power of Attorney) that amputation of the wounded leg was necessary or else sepsis would develop; however, the family (Daughter/Power of Attorney) opted for comfort and declined amputation. Resident #1 was discharged from the hospital on 05/18/20; and, the family agreed to Resident #1 returning to the facility on hospice - despite the doctor's recommendation of amputation. Medical records documented that Resident #1 had been under consistent care of registered nurses or hospital staff and all changes in the resident's condition were thoroughly communicated as well as to the resident's family (Daughter/Power of Attorney). Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Licensee did not bring changes in resident condition to the attention of the resident’s physician in a timely manner is found to be UNSUBSTANTIATED. Regarding Allegation #2 : this investigation revealed that Resident #1 was admitted to the facility on 12/26/17. A small sore was noticed on the resident’s leg on 04/16/20. Daily wound care by home health nurses began on 04/25/20 thru 05/06/20. During that time, the resident developed three (3) non-pressure wounds on the left, lower leg due to poor circulation. Resident #1 was admitted to the hospital on 05/14/20 because of poor circulation, which caused the wounds to open. Resident #1 had a skin integrity diagnosis before the sore developed; thus, it was not out of the ordinary for this resident to develop this wound. Resident #1's physician warned the family (Daughter/Power of Attorney) about sepsis without utilizing amputation; however, the resident’s family opted for comfortable measures instead. Medical records indicated that the family (Daughter/Power of Attorney) refused amputation and were advised of a potential result of a terminal illness. Resident #1 was discharged from the hospital on 05/18/20 and placed on hospice care and returned to the facility with the family's (Daughter/Power of Attorney) approval. Resident #1 passed away on 06/04/20 with a primary diagnosis of sepsis and a secondary diagnosis of non-pressure ulcer with necrosis of muscle. Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Questionable Death is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to Executive Director/Administrator, Remon Pagels.