complaint·February 6, 2023

emergency room after concerns regarding the pressure injuries were not adequately addressed by KP. Per hospital discharge paperwork dated 12/19/2022, R1 was seen for skin and rectal problems and a pressure injury of sacrum, stage 2. Resident was sent home same day with instructions on repositioning the resident and a reminder of wound care appointment on 01/06/2023. On 12/26/2022, Administrator contacted KP for a televisit regarding the wounds. No wound follow up by KP on this date. On 01/02/2023, Administrator submitted a request through the scheduling system for an appointment to address the pressure injuries. Administrator states no response from KP. On 01/05/2023, Administrator submitted once again for an appointment indicating the pressure injuries as reason for appointment. KP response was to remind Administrator of upcoming appointment on 01/06/2023. Administrator then took resident to KP emergency room again on 01/05/2023 where the resident was finally admitted. Hospital paperwork indicated the resident "has chronic ulcers of the shin and heels bilaterally which have not acutely changed. No new swelling, redness or discharge." Paperwork indicated seven wounds with two being unstageable. The wound on the left medial and lateral heel and right lateral malleolus ankle are deemed unstageable. Resident was admitted to the hospital from 01/05/2023-01/10/2023 and then transferred to a skilled nursing facility for further treatment. Administrator and staff indicate home health nurse not affiliated with KP was assisting facility with wound care. Home Health nurse indicates seeing the resident daily for approximately 10 days before hospitalization. Per Johns Hopkins medicine, patients with PVD have an increased risk of non-healing pressure injuries especially on the ankles and heels. Four out of four witnesses state Administrator was actively trying to get treatment for resident. Administrator denies any knowledge of pressure injury staging and indicates difficulty getting any information from KP regarding the resident's status. Due to conflicting information, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of this report was left at the facility.