complaint·July 26, 2021

Cadence Hospice ordered a DME bed to assist the resident in healing the stage 1 pressure injury. Per Dia, the bed arrived and was set up incorrectly by Cadence Hospice and the pressure was set too high. By the time Dia noticed the pressure settings he lowered the settings and informed Cadence Hospice who came to the facility and lowered the pressure further. Dia claimed that the staff were in fact repositioning R1 every 2 hours as well as making sure R1 did not sit in soiled diapers/clothes. On June 21, 2021, LPA August interviewed S1. S1 stated that the facility always has air central air conditioning as well as individual room air conditioners. There is no requirement to keep the AC off and the facility is always comfortable. In addition, S1 stated that the facility is always kept clean. Furthermore, S1 stated that she cared for R1 and repositioned R1 and kept R1 dry as was instructed from Administrator Dia and Cadence Hospice. S1 stated that the hospice staff never once told her she was doing anything wrong. On June 21, 2021, LPA August interviewed R1, R2 and R3. R1 stated that S1 or another staff member usually turns her and attends to her every 2 hours or so. She is never kept soiled for long and if she needs anything the staff are quick to help her. The facility temperature is fine and she had no issues or complaints with how she is being cared for. R2 stated that the caregivers at the facility are very attentive to her needs. Her room temperature is always kept comfortable and the facility is kept clean. R3 stated the facility is kept clean and he is free to use his room air conditioning as much as he wants. On July 26, 2021, LPA August interviewed Cadence Hospice staff S2. S2 stated that the facility was not repositioning R1 every 2 hours or ensuring that the R1 was kept dry and free from soiled diapers. As a result, R1 developed a stage 1 pressure injury at the facility that continued to develop into a stage 2 injury. S2 confirmed that Cadence Hospice ordered a DME bed for R1 to assist in healing the pressure injury and that the bed was setup incorrectly with a pressure setting that was too high but claims that this would not cause or hamper the R1's ability to heal from the pressure injury. As such, there is insufficient evidence to corroborate whether the above allegations have occurred. With the information obtained through the means described above, we have found the above allegations unsubstantiated. Although the allegations may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator Dia and a copy of this report was provided.