Complaint·September 19, 2023

The LPA took a cursory tour of the facility, conducted resident and Licensee interviews, and collected documents pertinent to the investigation. The LPA determined further investigation was required. Investigator Munoz conducted interviews on 08/15/2023, at approximately 3:37pm, with hospice personnel; and on 08/16/2023, from approximately 9:50am to 10:48am, with residents, including R1, and staff. In addition, the investigator reviewed hospice medical records, facility file documents related to R1, and staff personnel records. R1’s Physician Report, dated 03/21/2023, noted R1’s primary diagnosis as cellulitis right buttock. Secondary diagnoses listed as diabetes type 2, hypertension, anemia, heart failure, hyperlipidemia, hypothyroidism and osteoarthritis. R1 was admitted to the facility on 03/27/2023. According to the hospice medical records, R1 began receiving hospice services on 04/17/2023. R1 was placed on hospice with a diagnosis of recurrent sepsis. R1 has a history of recurrent E Coli UTIs. R1 is bedbound and requires use of a Hoyer lift for any transfers, and assistance for all activities of daily living except feeding. The records also indicated R1 has a stage 2 coccyx wound. The diagnoses and conditions listed in the records also included bacteremia, chronic kidney disease, type 2 diabetes, morbidly obese, and stage 2 pressure ulcer on sacral region. According to the clinical notes, R1 sometimes refused to eat, refused or was hesitant to take medication, and continued to have episodes of restlessness and agitation at night into the early morning hours. Additionally, the notes document that due to R1’s size, it is difficult for R1 to be moved in the bed without causing some discomfort. On the allegation: Licensee neglect resulted in resident developing pressure injuries. On 08/09/2023, a witness (W1) observed a closed pressure injury on R1’s coccyx area. W1 did not observe any pressure injuries to R1’s ear or elbow. The hospice notes document that the hospice nurse was treating R1’s wounds to coccyx Stage 2, left elbow Stage 1, and left ear Stage 2. The notes dated 08/07/2023 documented the wounds were healed and wound care was discontinued. On 08/10/2023, the notes indicated no specific changes were made to the current care plan and no new wounds were noted. Based on the information obtained, the Department did not find sufficient evidence to substantiate the allegation, therefore, the allegation “Licensee neglect resulted in resident developing pressure injuries” is unsubstantiated at this time. CONTINUED ON LIC9099-C On the allegation: Staff handled resident in a rough manner. The investigation revealed a witness (W1) visited the facility on 08/09/2023 and observed the staff reposition R1 in a rough manner. W1 witnessed R1 being repositioned suddenly and without warning. The investigation revealed that due to R1’s size, it is difficult to move and reposition R1. R1 requires two staff to assist in repositioning and transfers. R1 was interviewed and did not have any complaints about the facility or the staff. R1 denied ever being injured or handled rough by staff. Staff were interviewed and denied handling R1 in a rough manner. Based on the information obtained, the Department did not find sufficient evidence to substantiate the allegation, therefore, the allegation “Staff handled resident in a rough manner” is unsubstantiated at this time. On the allegation: Staff did not meet residents’ hygiene needs. It was alleged on 08/09/2023 W1 observed R1 had feces between their buttocks. R1 required assistance with toileting and/or brief changes. IB investigator observed the residents and facility were clean on 08/16/2023. LPA observed residents were clean on 08/14/2023 and 09/19/20223. Resident interviews on 08/14/2023 revealed that R1, R2, R3 and R4 denied any unmet needs including help with hygiene issues at any time. Staff interviews of S1, S2, and S3 on 08/14/2023 revealed that staff attended to all resident as needed and address all hygiene needs of residents in care. Based on the information obtained, the Department did not find sufficient evidence to substantiate the allegation, therefore, the allegation “Staff did not meet resident’s hygiene needs” is unsubstantiated at this time. Exit interview conducted, a copy of this report issued.