Complaint·October 23, 2024

Investigation Revealed the Following: Allegation: Resident developed a pressure injury due to staff neglect. The details of the complaint alleged that (R#1) developed a pressure injury due to staff neglect. During the records review gathered by CCLD staff, the department observed that (R#1) was admitted to Above and Beyond hospice on 6/4/24. The hospice prescribed and delivered a low-air mattress; when the prescribed mattress was delivered, the delivery person set it up and needed to share with facility staff how to operate the mattress. In addition, the department observed the records requested by CCLD staff regarding (R#1)’s wound care company “Wound Pros” Nurse Practitioner (NP) notes on 6/26/24, (NP) indicate that she provided education regarding the management of (R#1)’s air loss mattress to facility staff. Moreover, the department observed on the Physicians Certification for Hospice Benefit dated 6/11/24 from the hospice Registered Nurse (RN) that nothing is written about educating facility staff on operating new air mattresses (R#1). During an interview conducted by CCLD staff with facility administrator (A#1) on 7/31/24, she stated that when (R#1) moved into the facility on 3/30/24, they did not have any skin breakdown issues until transitioning to a new hospice agency (Above and Beyond Care) in 6/24/24. The new hospice agency provided a new air mattress that arrived on 6/5/24. When the delivery company dropped the bed off and, after setting it up, told the facility staff that the bed was ready for (R#1) to use. Neither the delivery company nor the hospice agency trained the facility staff to operate the mattress properly. (A#1) believes that the new air mattress was not set correctly and was too hard, causing (R#1) skin breakdown that led to a pressure injury. Moreover, (A#1) stated that on 6/26/24, a wound nurse from Wound Pros noticed the air mattress was not correctly adjusted and notified facility staff; the nurse properly adjusted the settings on the mattress and provided training to the facility staff on how to use the settings on the mattress properly. Evaluation Report continues LIC 9099-C During an interview conducted by CCLD staff with facility staff (S#1-S#2), (2) out of (2) facility staff stated that they deny the allegation of (R#1) getting a pressure injury due to their neglect, also (2) out of (2) indicated that they re-positioned (R#1) every two hours to prevent pressure injuries. In addition, (2) out of (2) facility staff indicated that the air mattress provided by the hospice company needed to be set up correctly despite the facility staff being told by the delivery person that the mattress was ready for (R#1) to use. During an interview conducted by CCLD staff with resident 1 (R#1), (R#1) was not able to answer (IB) investigator questions due to cognitive issues. During an interview conducted by CCLD staff with residents in care (R#2-R#3), (2) out of (2) residents stated that facility staff does a good job taking care of them and meeting their basis needs. During an interview conducted by CCLD staff with the son of (R#1) (W#3), they stated that when (R#1) lived at the facility, they never reported any complaints to them about the care they were receiving by the facility. In addition, (W#3) “think” (R#1)’s pressure injury started around the time the victim began using the new air mattress provided by the hospice company. (W#3) visited (R#1) regularly and did not see any neglect or lack of supervision on the part of the facility staff. During an interview conducted by CCLD staff with a Customer Service Representative with Horizon Oxygen Medical Supply Equipment (W#4), they stated that on 6/5/24, a new air mattress was delivered at the facility for (R#1)’s use. (W#4) stated that if the mattress was not set up correctly and the pump was off, the mattress could be under constant pressure, making it hard. In addition, (W#4) stated that no notes indicated that the facility staff had been shown how to use and adjust the mattress pressure. Evaluation Report continues LIC 9099-C During an interview conducted by CCLD staff with Wound Pro Nurse (W#5), they stated that they treated (R#1)’s pressure injury every week, and (R#1)’s wound was responding to treatment. In addition, (W#5) stated that when they saw (R#1) for the first time, they had an air-loss mattress that was set to static, which means it was fully inflated (firm); the mattress should not be set to static when trying to prevent pressure injuries. (W#5) spoke with facility staff (S#1-S#2) about the bed settings being static, and they informed them that the mattress was new and that they were not instructed on how to use or adjust it. (W#5) adjusted the mattress to the appropriate setting and provided training to (S#1-S#2) on how to properly adjust and use it. Allegation: Staff did not ensure that resident was provided an adequate amount of liquid(s) while in care. The details of the complaint alleged that (R#1) was not provided with fluids on a regular basis. During the records review, the department observed that in the facility's weekly menu, fluids are to be served as appropriate to each resident's needs. Also, the facility has a hydration plan that follows five steps: 1- give water at any time, 2—more often is much better, 3- they have a glass of water all the time beside their bed, and 4- give them water every day as requested. During an interview with the administrator (A#1), she stated that the facility offers enough water to the residents in care, and no resident has ever been dehydrated. During an interview with facility staff (S#1-S#2), (2) out of (2) stated that the facility provides enough water/liquids to residents in care, and no resident has ever been dehydrated before. During an interview with residents (R#2-R#5), (4) out of (4) stated that the facility provides water/liquids to them. Evaluation Report continues LIC 9099-C Allegation: Staff did not ensure that resident's diapering needs were met while in care. The complaint details alleged that facility staff did not regularly change (R#1)’s diapers. During the records review, the department observed that the facility has a diaper schedule with the following times: 7:00 AM, 11:00 AM, 3:00 PM, 7:00 PM, and 10:00 PM. During an interview with the administrator (A#1), she stated that the facility has a schedule for diaper changes, and no resident has ever been left with a soiled diaper for an extended period. During an interview with facility staff (S#1-S#2), (2) out of (2) stated that the facility has a diaper changing schedule and no resident has ever been left on a soiled diaper for an extended time before. During an interview with residents (R#2-R#5), (4) out of (4) stated that they have never been left on a soiled diaper for an extended period. Allegation: Staff did not ensure that resident's hygiene needs were met while in care. The details of the complaint alleged that facility staff did not ensure (R#1)’s hygiene needs were met. During the records review, the department observed that the facility has a shower/changing schedule and offers sponge baths to the residents almost daily. Evaluation Report continues LIC 9099-C During an interview with the administrator (A#1), she stated that the facility has a shower/changing schedule every day and as needed, and no resident has ever been left in soiled clothes for an extended period. During an interview with facility staff (S#1-S#2), (2) out of (2) stated that the facility has a bath/changing clothes schedule, and no resident has ever been left on soiled clothes for an extended time before. During an interview with residents (R#2-R#5), (4) out of (4) stated that they have never been left on soiled clothes for an extended period. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Antonia Dionisio /Administrator.