complaint·December 17, 2024

Interviews conducted with staff revealed R1 full assistance with all activities of daily living (ADLs). R1 required staff to reposition at least every 2-3 hours. Per staff R1 was check for incontinence as well provided care as needed. If soil during the times R1 was reposition R1 was change. Staff stated to notify any changes in condition to hospice as soon as observed, including when noticing the wound patches were soiled. Hospice will come to the facility to change them after notifying them. Staff were provided training by facility and hospice and were knowledgeable on the topic. Interview conducted with hospice care nurse revealed facility staff have provided proper care to R1 and facility’s staff have notified hospice immediately after observing a change in condition. Documents reviewed revealed the following, per physician’s report dated 2/15/24, R1 had a history of skin breakdown and needed assistance with all ADLs. On 10/10/24, R1 was recertified into hospice care. Under circumstances for hospice, it was noted R1 has a recurrent “skin issue, with a healed decubitus to the sacrum/coccyx”. It was noted R1 was bedbound. On 10/30/24 hospice nursing notes, note R1 is being reposition every two hours by facility staff. On 10/31/24, a meeting was held and per hospice meeting notes, R1 is “high risk for skin breakdown and skin breakdown prevention was provided to facility’s staff, family and caregiver by demonstrating care”. On 11/4/24 nurse (LVN) hospice noted, R1 was observed to have “redness on coccyx, left buttock, right hip, and right upper back and shoulder”. R1’s facility resident assessment dated: 11/11/24 notes, R1 required “complex wound care”, which was to be provided by a nurse as order by physician. Hospice physician order dated 11/11/24 notes an x-ray was requested to rule out fracture for hand due to redness and swelling. Wound care was requested for right shoulder and lower back. Per Outside Agency - facility’s form, on 11/11/24 LVN visited R1 and provided wound care. On 11/11/24 facility provided skin integrity training to staff. Order summary report dated: 11/13/24, notes R1 will be receiving wound care for a stage II sacrum pressure ulcer three times a week. On 11/18/24 hospice physician conducted an in person visit and noted R1 has various lesions in the body and a stage I wound in the sacral area due to “frail skin”. Per physician these are "unavoidable" due to R1’s condition and may be "difficult to heal". Although the wounds may have developed based on physician’s notes on R1’s declining condition there is not enough evidence staff's lack of care would have cause 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. Exit interview was conducted with Laura Sanchez Health Care Director and a copy of this report was provided.