Complaint·January 29, 2025

Allegation: Staff did not adequately assist resident with repositioning. The complaint allegation alleges that due to not being repositioned frequently resident has developed redness on the sacrum and a blister on their heel. During record review the department received and reviewed R1’s Physician Report dated 07/26/24 that indicated the resident is nonambulatory. Additionally, the Physician’s Report indicated R1 requires Continuous Bed Care, requires assistance with Incontinence, and is unable to transfer independently. Additionally, during record review the department received and reviewed R1’s physicians request for home health services dated 09/12/24. On the referral, the department observed, R1 was diagnosed with a “pressure ulcer of left heel stage 1.” During the facility tour, the department observed a board in the Medication Room that indicated Alert Charting that had R1 listed for wounds on both heels. Additionally, the department observed a Reminder Schedule for all shifts to assist R1 with repositioning or transferring, and incontinence care every two (2) hours. During record review, the department received and reviewed staff training logs from Relias for five (5) Staff. The department observed five (5) out of five (5), have had trainings including The skin and Pressure Injuries, Proper Positioning, and Recognizing and Reporting Skin Conditions. During interviews with Staff S1-S10, were asked how often a resident who requires assistance with repositioning is assisted, ten (10) out of ten (10) stated they help residents reposition every 2 hours. Additionally, Staff S1-S10 were asked how frequently residents are checked for pressure injuries, ten (10) out of ten (10), stated residents are checked daily. During interviews with Residents R2- R10, were asked if they have sustained pressure injuries while in care, nine (9) out of nine (9) stated they have not sustained pressure injuries while in care. Additionally, R7 and R8 stated staff assist them with repositioning on a regular basis. During interviews with the Home Health Agency Nurse (W1), indicated on their visit on 09/25/2024, it was recommended to staff to reposition Resident R1 every 2 hours, apply ointment or lotion to the heels, and continue using cream the doctor ordered. During an interview with W1 on 10/03/2024, they indicated the bottom was looking better and the heels were worse. W1 recommended to elevate heels off the bed, apply lotion or ointment, cover the heels with band aids and put socks on when R1 is in the wheelchair and continue to reposition every 2-3 hours. Additionally, during an interview with W2 on 10/10/2024, indicated they showed care staff how the feet should be elevated to keep pressure off the heels, keep R1’s heels covered when in their chair and uncovered when in bed to dry out, and to continue to assist with repositioning every 2 hours. During facility visits, the department observed R1 in their wheelchair. R1 had their heel covered with a bandage and socks on. Additionally, the department observed pillows and cushions on the wheelchair to help protect the heels. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . An exit interview was conducted with Executive Director, Judith Uy and a copy of the report was provided.