Complaint·July 14, 2022

An interview conducted on September 29, 2020 with facility Staff1 (S1) revealed R1 received home health services three (3) days a week. S1 also revealed on August 3, 2020 they observed a small blister on R1’s lower back. S1 notified the facility Administrator (S2) on that same day. Interviews with S1 and S2 revealed on August 4, 2020 R1’s primary doctor and home health agency were notified about the pressure injury. An outside source record review corroborated that on August 4, 2020 facility staff notified R1’s home health agency and R1 was seen by a nurse on that same day. Interviews with facility staff and an outside source record review also revealed on, August 4, 2020, R1’s attending nurse instructed facility staff how to care for R1’s wound. An interview with S1 revealed on August 7, 2020 R1’s injury appeared to have worsened and S1 facilitated having R1 transported to the emergency room (ER) of a hospital. A review of medical records corroborates R1 was transported to the ER on August 7, 2020. It was also alleged facility staff failed to seek medical attention for R1, and the facility retained R1 with a restricted health condition. An interview with S2 revealed toward the third week of July 2020 R1 began to have trouble swallowing, and R1 started to refuse to eat their pureed food. R1 also developed a pressure injury while at the facility. Staff and outside source interviews, as well as resident and medical record reviews revealed at the time of the alleged violations R1 was under the care of a home health service and was being seen by medical professionals three times a week. Both the home health agency and R1’s primary doctor were informed and aware of R1’s prognosis. Due to lack of corroborating evidence, the finding regarding the above allegations were established to be unsubstantiated. This finding means there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Caregiver Pascua and a copy of this report along with Licensee Rights (LIC 9058 01/16) was provided to Caregiver Pascua. Signature on the for confirms receipt the reports were received.