complaint·September 20, 2022

A witness interviewed stated that at admission R1 had an elbow wound, but that R1’s medical providers did not give a stage or diagnosis for this wound. LPA reviewed R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) (LIC602A) dated 08/13/22 which does not list any diagnosed wounds, sores, or pressure injuries. AD stated that when R1 was admitted, R1 was already on hospice. AD stated that during R1’s stay at the facility, hospice provided wound care for the small pink area which developed into an open wound despite the wound care and regular turning and rotating of R1 every 30 minutes. LPA reviewed R1’s Hospice Care Notes dated from 08/18/22 to 09/02/22 which indicate that no wound was noted on R1 until 09/02/22 when hospice noted an open wound and that wound care was provided. AD stated that on 09/10/22, the wound grew rapidly and the facility called hospice who came to came to provide wound care on 09/10/22, 09/11/22, and 09/12/22. AD stated that on 09/12/22 hospice stated the wound was unstageable and that R1 had respiratory issues. On 09/12/22 R1 was taken to the hospital for respiratory issues where R1 was diagnosed with an unstageable wound. A witness interviewed corroborated AD’s statements and had no concerns about abuse or neglect and had no complaints about the facility. While R1 developed an unstageable wound at the facility, R1 was on hospice and the facility was allowed to retain R1. The facility coordinated wound care for R1, turned and rotated R1 regularly, and worked closely with R1’s family and medical providers to ensure R1 received proper care for the wound. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.