complaint·August 3, 2021

The investigation revealed the following: Facility staff did not submit paperwork needed for resident's prescribed wheelchair In interviews, R1, W1, and W2 stated that they sent multiple requests to S1 to send the paperwork needed to order a wheelchair and cushion for R1. S1 confirmed that an electric wheelchair and cushion was requested by R1, but that the vendor took a long time to come to the facility to do the face-to-face evaluation, which is required prior to ordering. After the evaluation was completed in March, S1 stated that the vendor requested a physician's signature on the completed evaluation form. Per S1, the facility sent the paperwork to R1's physician in April. S1 stated that there was a delay because the vendor said they never received the paperwork and the facility had to contact the physician to re-send it. W1 stated that process takes from 4-6 weeks from start to finish but they could not move forward without physician's signature on the evaluation form. On 3/31/21, R1 was sent out to a skilled nurse facility for almost two months. S1 stated that the physician signed and submitted the paperwork, but the vendor would not deliver the wheelchair/cushion to facility while R1 was out. S1 followed up with the vendor when R1 returned and confirmed that they could deliver the items within 7 business days. In follow-up interview, R1 stated the problem was resolved and that the wheelchair and cushion arrived about 2 weeks ago, and was observed by LPA during the subsequent visit on 8/3/21. Resident sustained a stage four pressure injury while in care Staff interviewed stated that residents with pressure injuries are treated by a home health agency or are sent out to a skilled nursing facility. Assistant administrator stated that R1 had a stage three pressure injury when R1 was sent out in March. A review of R1's physician's report and medical records shows that R1 has a history of skin breakdown and is being monitored by home health. R1 stated that due to a previous skin flap surgery, any subsequent pressure injuries in the same area are automatically staged at a stage 3 or 4. According to R1's medical records, R1 was evaluated for a stage 3 pressure injury and has a wound care plan in place. Staff and R1 stated that R1 did not want to be treated by home health at the time, so R1 was sent out to skilled nursing. Medical records revealed that R1 was admitted to the skilled nursing facility on 3/31/21 and was discharged on 5/9/21. R1 stated that the pressure injury was minor and had healed within two weeks, but had to stay longer in the skilled nursing due to another medical issue. Based on interviews, observations and records reviewed, the findings indicate that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with the assistant administrator and copy of the report was provided.