complaint·October 12, 2024

The investigation revealed the following: Regarding allegation: Staff did not properly handle resident's wound care and Due to staff neglect, resident's wound worsened while in care. It is alleged R1 was admitted to the facility with a bedsore, it was said that “it was healed, when actually it was not”, and the wound was never packed nor were antibiotics given until October 2, 2023. On 7/5/23 R1 was referred to a hospice agency. On 7/6/23, R1 was admitted to the facility and hospice services were initiated. On 7/7/23, hospice conducted an initial evaluation which noted R1 had a stage II sacrum pressure sore and Moisture Associated Skin Damage (MASD) to the groin area. Hospice care notes were to apply ointment and cover. On 7/9/23, R1’s private caregiver reported R1 wouldn’t allow to be change or repositioned to hospice staff. On 7/10/23, hospice nurse noted that the care needs of R1 were explained to the caregiver. On 7/13/23 hospice notes were noted that wound “worsen” from a stage II to a stage III wound. On 7/18/23 Facility’s notes state, facility’s staff was notified by hospice staff that prior to admission R1 was discharge from the hospital with antibiotics and a stage one pressure ulcer which progressed into a stage II-III. On 9/25/23, Hospice noted that R1’s stage III wound reopened. On 9/30/23 Hospice noted R1 was started on antibiotics. On 10/1/23 Hospice nurse noted a second antibiotic was prescribed for R1. On 10/2/23 hospice agency noted wound was now at a stage IV. On 10/2/23 Hospice agency provided instructions to pack and oral antibiotic (ATB) for possible infection. On 10/3/23 R1 was send out to the hospital per family’s request for higher level of care. Two physician’s report were reviewed for R1 initial physician report dated 6/7/23 notes R1 had no history of skin breakdown. However, Physician’s report dated 7/7/23 notes R1’s history of skin breakdown with a stage III wound to the coccyx and ambulatory status changed to bedridden. The physician noted the change of ambulatory status is due to “continuous declining”. On 9/20/24 R1 was seen by a wound master specialist, who noted will provide services once a week. Wound care was provided per wound specialist orders by hospice and staff. Hospice visits were provided based on the care needed from once a day and additional 3 times per week, if necessary, upon initiating hospice. Staff interviewed stated to have been repositioning resident as recommended by hospice at least every two hours and sometimes more frequent. Although the wound worsened within two months, R1 was receiving Hospice services upon admission and health care provider was providing care for the wounds. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. (CONTINUED ON LIC 9099C) Regarding allegation: Staff did not note changes in resident's medical condition and Staff did not seek resident timely medical attention. It is alleged wound had gotten worse and medical attention was not sought. R1 was admitted to the facility on 7/6/23, preplacement appraisal dated 6/29/23 notes a health in condition change prior being admitted to the facility. Facilities progress notes reviewed between 7/6/23 to 10/19/23 revealed facility charted R1’s changes in condition, hospice visits, R1’s routines, per resident’s need (PRN) medication provided, and communications with family members. Facility noted twelve of the visits provided by hospice in which hospice either provided additional care or instructions to the caregiving staff. There was a total of three hospital visits per family’s request and concerns on 7/13/23, 7/20/23, and 10/3/23. Hospice documents revealed upon R1 starting services on 7/7/23 was scheduled to be visit by a skilled nurse professional daily and three additional times PRN. On 7/13/23 hospice order a low air loss (LAL) mattress due to change in condition. R1 had a change of condition related to the wound which were noted and followed up by hospice care and noted by the facility. On 7/18/23, a meeting was held with R1’s family to provide information of higher level of care as well as the difference between hospice and higher level of care. Wound Master initiated services on 9/20/23, observations of R1’s condition by facility staff were reported to wound care specialist. Wound care specialist provided treatment and instructions of care to facility staff and hospice. Wound care visits were schedule for once a week after 9/20/23. Interviews conducted with residents and staff revealed that facility provides timely care and respects resident right to call for emergency services as needed. Even though R1 had a decline in condition, R1 was being provided care by a skilled nurse professional and upon family requesting hospitalization R1 was transfer to a hospital. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Staff did not provide resident's family with a copy of the resident's wound care plan. It is alleged wound care specialist was to develop a plan, which the family could request a copy of, family and it was never received from the facility. Interviews conducted with 10 residents revealed that they have not had the need to request copies of records. However, they felt that the facility will provide them with copies if necessary. Interviews with staff revealed that the facility will provide copies to the resident or power of attorney upon request. Interview conducted with administrator revealed that documents were not requested for R1’s medical records. Interview conducted with family representative revealed that documents were requested to hospice agency. (CONTINUED ON LIC 9099C) Interview conducted with hospice agency revealed the family did not request any documents. Hospice documents reviewed revealed family was informed of resident’s condition or provided updates each time nurse provided care, which was almost daily. Wound Master provided an initial evaluation and provided care to R1 on 9/20/24, hospice agency provided updates to R1’s family on 9/20/24 and 9/21/24 no notes on family requesting documents or copies of plans were observed. Family representatives may have asked for copies of wound care plan. However, there are no records to indicate that the family requested R1’s medical records to facility staff. Therefore, there is not sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility retained a resident requiring a higher level of care. It is alleged facility staff and hospice staff attempted to have the family hold off on the ambulance to transfer R1 to a hospital. Interviews conducted with residents revealed residents feel facility staff would assist them with emergencies in a timely manner and feel confident that facility will assist them with obtaining medical assistant in a timely manner. Interviews with staff revealed, staff are aware that if a resident, power of attorney, or family representative chooses to send the residents to the hospital they are to follow the decision taken even if the resident is on hospice. Documents review revealed that R1 was taken to the hospital on three different occasions on the following dates: 7/13/23, 7/20/23, and 10/3/23 per family’s health concerns and request. Facility notes show that on 10/3/23 family requested emergency responders to be contact to take R1 to the hospital for treatment of infected wound. Per hospital records R1 arrived at hospital on 10/3/23 and was admitted on 10/5/23 to be seen for infection of sacral wound. Although the allegation may have happened, documents reviewed note R1 was receiving care by a skilled professional, as well as visited the hospital in three occasions, and was transfer to the hospital on 10/3/24 upon family’s request. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided.