complaint·May 31, 2024

On 7/7/2023, R1 started receiving hospice services. R1 continued to receive services from his/her two private nurses. Records reflect that on or about 8/5/2023, a hospice nurse noted that a red area was developing on R1’s buttocks. At the time of the observation, PN 2 was present and made aware of the red area. The nurses treated the area and decided to monitor it. On 8/17/2023, PN 1 was contacted by a hospice nurse and facility staff regarding the red area on R1’s buttocks. PN 1 informed the nurse and staff that he/she was out of town and provided instruction as to how to clean the wound. PN 1 made the nurse aware that he/she would be back that night and check and reevaluate the next day. The hospice nurse noted that upon assessing the red area, the wound was closed. The skin was peeled off from cleaning, and R1’s buttocks appeared to have a light yellow film. There was no drainage or sign of bleeding at the time. R1’s physician was made aware of the wound through photos that were sent by PN 1 and facility staff. On 8/18/2023, at or about 1:00 PM, PN 1 visited R1 and tended to R1’s wound. PN 1 was not aware that there was a deep abscess in the area and began to compress on it, at which time it excreted pus and bodily fluid. At this time, PN 1 called 911, paramedics arrived, and R1 was transported to a local hospital. Hospital records note that the physician reported the chief complaint to be an area of infection with purulent drainage to the right buttock. On 8/30/2023, R1 was discharged from the hospital to a skilled nursing facility. Interview of R1’s physician, conducted during the investigation, revealed that the abscess was unforeseen, and the facility’s caregivers had nothing to do with the development of the abscess. R1’s physician noted that R1’s complex medical conditions caused the abscess to develop without symptoms. R1’s physician made it clear that R1 did not have a pressure injury on the buttocks, as was reported, but had an abscess. R1’s physician also noted that facility staff communicated with the physician, as needed, regarding any questions or concerns relative to R1’s care, and facility staff provided excellent care to R1. One of R1’s hospice nurses also noted that the facility’s caregivers were well trained, provided extra care, did a really good job, and were able to take care of R1 with all the services he/she required. Relative to the report of R1 sustaining multiple stage 2 pressure injuries on ankles and feet, records reviewed during the investigation indicate that water blisters had developed on R1’s hands and feet; however, there was no evidence obtained to indicate that R1 sustained pressure injuries in any of those areas. The third allegation is that R1 did not receive timely medical attention. According to evidence obtained during the investigation, R1 had been receiving frequent care from hospice nurses and his/her private nurses, PN1 and PN 2. Prior to PN 1 compressing on the area that was later determined to be an abscess, there was no indication to facility staff that R1 had a sudden need for medical attention. At the time that PN 1 compressed and expressed fluid from the abscess, R1’s condition worsened which triggered the need for medical attention. At that time, PN 1 called 911 and had R1 transported to the hospital for medical care. Based on all of the foregoing, the above listed allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Tess Derafera, and copies of this report and Licensee/Appeal Rights (LIC 9058) were provided to the administrator at the conclusion of the visit. Administrator’s signature on this report acknowledges receipt of copies of the rights and report. Records reflect that on or about 8/5/2023, a hospice nurse noted that a red area was developing on R1’s buttocks. At the time of the observation, PN 2 was present and made aware of the red area. The nurses treated the area and decided to monitor it. On 8/18/2023, PN 1 visited R1 and tended to R1’s wound. PN 1 was not aware that there was a deep abscess in the area and began to compress on it, at which time it excreted pus and bodily fluid. At this time, PN 1 called 911, paramedics arrived, and R1 was transported to a local hospital. Hospital records note that the physician reported the chief complaint to be an area of infection with purulent drainage to the right buttock. The investigation did not yield evidence to conclude that there was a change in R1’s condition until PN 1 compressed the abscess which excreted bodily fluids in response to the compression. Records reviewed and interviews conducted during the investigation revealed that PN 1 has been granted durable power of attorney by R1. Accordingly, if notification was to be provided, it would have been provided to PN 1, who was present and actively involved when the identified change in R1’s condition occurred. Based on the foregoing, we have found that the complaint allegation is unfounded, meaning that the allegation is without a reasonable basis. Therefore, as to the above listed allegation, the facility is in compliance with Title 22 regulations at this time, and we have dismissed the complaint. An exit interview was conducted with Tess Derafera, Administrator, and copies of this report and Licensee Rights (LIC 9058) were provided to the administrator at the conclusion of the visit. Administrator's signature on this report acknowledges receipt of copies of the rights and report.