complaint·August 30, 2023

Hospital records showed R1 arrived at the emergency department on 12/17/2020 at about 08:53 PM. Chief complaint was weakness as R1 had not been eating the past few days and has been weak and lethargic. R1 was diagnosed with severe sepsis with acute organ dysfunction, septic shock, dementia, myasthenia gravis, anxiety disorder, failure to thrive syndrome, sever protein calorie malnutrition, left ventricular mural thrombus, ischemic cardiomyopathy, coagulopathy, hypernatremia. Multiple pressure ulcers on left toe, right ankle, right lower leg, and coccyx (unstageable), right heel stage 1, and deep tissue pressure injury of right and left heel. Apex Hospice Care was approved for R1 from 12/04/2020 – 03/03/2021; Primary diagnosis – Senile degeneration. Records showed R1’s health was declining, with poor appetite, difficulty in swallowing, lethargic, and poorly responsive. Interviews with Apex Hospice staff (Registered Nurse, Licensed Vocational Nurse, Physician Assistant) revealed they observed left heel with suspected deep tissue injury, blister to right ankle, redness to buttocks, and bruising to upper and lower extremities during their visits, from 12/10/2020-12/15/2020. No other pressure injuries noted on R1’s body. Hospice staff stated they did not have any concerns regarding the pressure injuries, and they were monitoring R1’s condition at that time. Instructions were given to Atria care staff to apply calmoseptine, floating the heel, and to reposition R1 frequently as tolerated. All observations were documented on the visit notes. Hospice staff stated they notified appropriate individuals of R1’s declining health condition. Home Health Aide who came two times per week to assist R1 with bathing stated she did not observe any pressure injuries or bruises on R1’s body. Atria Golden Creek records documents staff noticed R1 with swollen discoloration on left arm near antecubital area on 12/08/2020 and with redness in R1’s perineal area on 12/09/2020. Hospice, family member who is also a Power of Attorney (POA), and physician were notified and staff was to continue to monitor the area and follow Dr.’s orders (medicated powder). No other documentation regarding skin discoloration or pressure injuries were observed anywhere else on R1’s body. No other observation/notes for R1 from 12/11/2020 – 12/16/2020. Atria Golden Creek’s Executive Director Nicole Wentworth and Resident Services Director April Princesa were interviewed. Wentworth and Princesa were shown photographs of R1’s pressure injuries that were taken at the hospital (12/18/2020). Wentworth and Princesa acknowledged the pressures injuries were “severe”. Both stated they were not made aware by their care staff of R1’s skin condition. Both stated, “We [care staff] missed it. We should have seen it.” Both could not provide an explanation as to how the care staff were not able to notice and document the pressure injuries. Wentworth stated R1 was residing in their facility and was under their care and supervision and took full responsibility. Wentworth stated she will provide additional in-service staff training for the care staff. All necessary interviews have been conducted. Atria and Apex Hospice staff failed to observe, document, and treat all of R1’s pressure injuries prior to R1 being transferred to the hospital on 12/17/2020. The investigation provided sufficient evidence and corroborating information to Substantiate the allegation of Neglect/Lack of Care and Supervision of resident R1. An exit interview was conducted with Administrator Craddoc. A copy of the following reports LIC9099, LIC9099C, LIC9099D, LIC421M, LIC9099A, LIC811, and Appeals Right was sent to email on file.