complaint·May 7, 2025

traumatic wound to left lower dorsal leg. In the same discharge assessment date 12/23/24 R1 is noted to have new skin tears, and it is unknown as to how R1 sustained “so many new skin tears”. Per a file review conducted of Unusual/Incident/Injury report review there were no reports of any falls. Per the home health progress note revealed that R1 requires max assist when transferring from their bed to wheelchair. Home health services commenced on August 8, 2024. Home health is noted to come out to the facility every seven days (7). The third party wound care agency commenced services on 11/8/24 -12/17/24 and was coming out every six (6) days. On 11/8/24 R1 was observed to have a wound to their lower left anterior leg that was not healing despite measures taken such as topical antibiotics, Santyl, Medi honey, and Collagen. The wound is described as being a result of venous insufficiency, resulting a procedure was performed to remove slough and necrotic tissue. Per records reviewed of home health agency progress notes, “R1s left leg wound was noted to make no improvement and had worsened with drainage without significant improvement”. R1 is noted to have sustained additional wounds and the recommendation was to have skin grafting procedures completed”. Further notes reviewed revealed R1 is noted to have sufficient nutrition as well as normal oxygen level, the recommendation as noted in the home health progress notes was to reposition R1 every two (2) hours. Per R1s narrative charting the third party wound care specialist agency states in the notes for R1s dressing to be changed every 2-3 days as needed. Per an interview with Executive Director Tammy Eddy “facility staff were provided wound care training as well as the status of R1s condition was reviewed in regard to any applicable changes”. “Further due to the facility being non-medical, any wounds are reported to the primary care provider, and they refer out to Home Health for wound care”. Tammy further stated that the staff did not see the wounds as they were covered. Per additional staff interview conducted training was conducted which consisted of reporting observations of any wounds observed, and to apply basic first aid if applicable. Basic first aid consists of cleaning the wound with a wound solution spray and applying a bandage or gauze. Staff denied that the dressings were to be changed by facility staff, as home health or any other agency is involved, the responsibility is to report to the Primary Care Physician and keep following up until the resident has been seen by the necessary party. Despite efforts taken little to no improvement was made and a Hospice recertification was completed, and R1 received hospice services from 12/23/24 -1/31/24. Per a record review on R1s narrative charting, R1 is 12/23/24 R1 was admitted to a local hospital with the diagnosis of chronic wounds. On 1/31/24 R1 passed away and was unable to be interviewed in regard to the complaint allegation. Based on interview and record review the allegation of Staff neglect resulted in a resident sustaining multiple pressure injuries is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted and a copy of this report, LIC811-Confidential names list was reviewed and provided to Patricia Russell, Resident Services Director.