Complaint·August 19, 2025

(Continued from Page 1) Other conditions noted were mild cognitive impairment (MCI), pressure sores on heel and sacrum, required continuous bed care due to unable to sit/stand, motor impairment/paralysis, and deconditioning. R1 needed assistance with all activities of daily living (ADLs), was considered bedridden, and required assistance with turning or repositioning in bed. A review of medical records revealed that R1 was hospitalized from 04/01/2023 until 05/04/2023. The discharge summary stated R1 was readmitted on 04/01/2023. The discharge summary also documented that R1 had been admitted previously from 02/24/2023 to 03/02/2023 and discharged to a skilled nursing facility. The initial wound care consultation on 04/02/2023 noted the presence of suspected pressure injuries on the left buttock, sacrum, and the left heel (DTI) deep tissue injury. The wound care consultation on 05/04/2023 documented that the pressure injury on the coccyx was at a Stage 3 and the DTI on the left heel was still present. The medical records also revealed R1 was admitted to the hospital on 06/07/2023 and the diagnosis included a pressure injury on the sacrum that was at Stage 4 (muscle, tendon or bone). R1 was discharged on 06/10/2023 with instructions to continue wound care. The medical records further revealed that R1 was seen again at hospital on 08/10/2023 with diagnosis of pressure ulcer of coccyx Stage 4 and admitted from 08/25/2023 to 09/11/2023 with diagnosis of buttock cellulitis. On 10/02/2023, R1 was seen by plastic surgery to evaluate the Stage 4 pressure injury. The wound was cleaned and debrided. Plastic surgery was not done. It was recommended for R1 to be seen at the wound clinic in November 2023 to discuss the possibility of a flap. On 10/03/2023, R1 was admitted to the hospital with an altered level of consciousness. The diagnoses made at the emergency room included gastrointestinal hemorrhage, anemia due to acute blood loss, coagulopathy (a condition in which the ability of blood to coagulate is impaired), UTI, and severe sepsis with organ dysfunction due to UTI. It was also documented that R1 had a Stage 4 sacral pressure injury with no surrounding redness. The nursing note upon admission documented that R1 had multiple bruising throughout R1’s body. (Continued on Page 3 (Continued from Page 2) The hospital personnel reported that it was possible that the bruising was a result of neglect. The Nutrition Initial Assessment conducted on 10/04/2023 documented multiple wounds at varying stages throughout her body. There was no mention of bruising. A review of the Home Health Care medical records revealed the start of care assessment was conducted on 05/05/2023 and it documented a small sacral pressure injury. The initial LVN visit, made on 05/09/2023, does not mention the stage of the pressure injury. On 05/27/2023, the LVN documented the sacral pressure injury to be at a Stage 2. By 05/31/2023, the pressure injury was at a Stage 4, measuring 2.6 cm long by 1.6 cm wide and 1.5 cm deep. Instructions were given to caregivers on how to turn R1 every two hours. According to the documentation, the pressure injury stayed at Stage 4 ever since and only grew in size to 6 cm by 08/07/2023. The records also show that R1 was getting daily wound treatment by Home Health nurses September 2023 until 09/20/2023. R1 was then seen every five days until the last treatment on 09/30/2023. On the allegation: Neglect/lack of supervision resulting in pressure injury. The evidence collected during the Department’s investigation was not sufficient to substantiate that neglect or lack of care led R1 to develop a Stage 4 pressure injury on R1’s coccyx. R1 was admitted to the facility with orders for home health services to treat the wounds. The facility staff also received instructions on pressure injury prevention that included repositioning R1 to relieve pressure off the coccyx. Facility staff stated that they followed these instructions. Even though wound treatment was provided by skilled nurses from the home health agency and the facility staff repositioned R1 every two hours, the pressure injury on the coccyx progressed to a Stage 4 by 05/31/2023 and stayed at Stage 4 until R1 left the facility on 10/03/2023. During the time R1 was placed at the facility, R1 was sent to the hospital on four separate occasions to evaluate the pressure injury. R1 was discharged back to the facility each time with orders for home health treatment. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Neglect/lack of supervision resulting in multiple bruises. (Continued on Page 4) (Continued from Page 3) Although the medical records mention the presence of multiple bruises on R1 upon admission at the hospital on 10/03/2023, the evidence was not sufficient to substantiate that the bruises on R1 seen at the hospital were a result of neglect or lack of care by facility staff. R1 had a diagnosis of “antiphospholipid syndrome”, the Mayo Clinic defines this syndrome as a condition in which the immune system creates antibodies attacking tissues in the body. These antibodies can cause clots to form in the arteries, leading to heart attacks and strokes. R1 was treated with blood thinning medications. The Home Health nurse did not document any bruising on R1 on the visits prior to 10/03/2023. The hospital records mention the bruising, but there is no follow-up or explanation for its cause. The Administrator stated that she was aware of the bruise and spoke to the home health nurse about it and was told that it could be due to the blood thinner medications that R1 was taking. The Administrator denied any type of abuse or accidental falls. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted with Adulfa Garcia, copy of this report, LIC811 was issued.