complaint·April 15, 2025

The investigation revealed the following: Allegation: Resident sustained a severe pressure injury due to staff neglect. It was alleged that resident developed the bed sore due to due to staff neglect, not being rotated. Per hospice and facility records obtained by the Department, it was discovered that R1 was admitted to the facility under hospice care services due to R1’s health condition. Prior to R1’s admission to the facility, she was at SNF. According to Family Member 1 (FM1) When R1 arrived at Morningstar of Pasadena facility R1 had “complexity of health issues” which resulted R1 to become bedbound. FM1 indicated per S3, R1 developed the pressure injury due to not being rotated. Interviewed Family Member 2(FM2) indicated that they were not aware of R1’s health conditions and stated that R1 kept it confidential between themselves and their doctor. Interviewed S1 and S2 indicated that during R1’s admission, she had a presented pressure injury on her coccyx which would open and close through the course of being alive at the facility. For a while R1 was ambulatory, but overtime while R1 was living in the facility, R1’s health was declining. Interviewed staff stated R1 was provided care by a hospice nurse and the facility’s staff. Interviewed S1 and S2 denied the allegation. They stated that facility staff did not neglect R1’s which resulted in a pressure wound deteriorated. They stated that R1 had a psychological and eating issues. S1 and S2 stated that Facility staff encouraged R1 to dine with their family members, to increase R1’s mobility but R1 became uncomfortable and depressed. Facility staff ended up feeding R1 in their room when R1 completely became bedbound. Interviewed staff stated that every two to three hours staff were responsible for rotating and repositioning R1 as instructed by hospice. Interviewed S3 stated that caregivers not allowed to provide wound care. Only LVNs and Hospice nurses. S3 stated that R1’s wound progressed while R1 was at the facility, but not able to provide any details or verify if the pressure injury was evaluated. S3 indicated that facility staff and caregivers were given instructions by Hospice staff and facility LVNs to rotate and reposition R1 every 2 hours. Interviewed Staff indicated that Hospice nurses came to the facility twice a week and provided comfort care and wound care to R1. Hospice document review revealed that hospice staff observed R1 was well cared, and hospice staff did not have concerns during visit. Due to the R1’s health condition, it was hard to prevent R1 from to sustaining pressure wounds, regardless of how well the wounds were being cared for and how often R1 was being repositioned/ rotated. Per hospice staff notes / reports, facility staff were provided good care to R1 and followed all instructions from Hospice. R1 passed away at the facility on 07/22/23 while a hospice care nurse and Family members were by R1’s side. Death certificate notes R1 passed away due to Atherosclerotic Cardiovascular disease. Therefore, this allegation is unsubstantiated. Continue 9099C Allegation: Staff are not properly trained. It was alleged that Facility staff not trained how to rotate the residents and haven’t been instructed on what to do. Per hospice and facility records obtained by the Département, it was discovered that R1 was admitted to the facility under hospice care services due to R1’s health condition. Review of documentation obtained from Hospice and facility revealed that R1 was being treated for pressure injuries. Documentation also shows that facility staff were given the instruction to rotate the resident every two hours to relieve pressure. During the interviews with staff, department was advised that the facility caregivers followed the instructions from the Hospice care and the residents care plan. Interviewed staff stated that every 2-3 hours staff were responsible for rotating and repositioning R1 as instructed by Hospice. Rotations were documented using the PCC (old) and Alis (new) program. In service training on Rotating Residents every 2 hours was provided to facility staff. Department obtained and reviewed the training materials for residents rotation and staff Certificates of Completion for Proper Positioning, Care tracking sheets. Facility staff also demonstrated how is working the program and was observed that staff documented / signed all services and cares provided to resident, including repositioning in the system. All caregivers were able to log in the care system using their cellphones. Based on the record reviews, observations and interviews conducted with staff there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted and the copy of this report was provided to Executive Director.