Incident investigation·April 23, 2021

Licensing Program Analyst (LPA) Ashley Smith initiated a Case Management-Incident visit to conclude an investigation initiated during a previous Case Management visit conducted on 4/1/2021. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Marian Rubenstein. The LPA also discussed the findings with Administrator Inga Jakobovich. On 04/01/2021, the facility submitted an Unusual Incident Report, noting that on 3/16/2021, redness was observed near Resident #1's (R1) coccyx. R1 was taken to urgent care and home health was initiated. Per the report, the wound was staged as a Stage 2, possibly a Stage 3 pressure injury. A wound specialist assessed the wound and daily nursing visits began 3/18/2021. The wound was reassessed on 3/30/2021 and it was identified as a Stage 4 pressure injury. R1 was transported to the hospital on 3/30/2021. The Administrator stated that they left a message for the On-Duty Worker regarding this incident on approximately 3/19/2021. During the 4/1/2021 visit, the LPA completed a tour, interviewed Ms. Jakobovich, and requested documents. Records review and interviews revealed that on 3/19/2021, a wound specialist observed R1’s coccyx and noted the wound as a Stage 3 pressure injury. The facility initiated wound care, and the facility fulfilled their obligation to treat the wound as required, along with repositioning R1 every two hours. On 3/25/2021, an assessment was conducted on R1, and the pressure injury on the coccyx was noted as unstageable. Subsequent visits on 3/28/2021, 3/29/2021, and 3/30/2021 documented the pressure injury as unstageable. On 3/30/2021, R1 was transported to the hospital and is currently recovering at a skilled nursing facility. Based on the information obtained, there is sufficient evidence to confirm that the facility retained R1 in the facility with a prohibited health condition, as R1’s wound was noted as a Stage 3 pressure injury, which eventually became unstageable. In addition, the facility did not submit an incident report for the 3/16/2021 urgent care visit. The following deficiencies will be cited (refer to LIC 809-D). Exit interview conducted. A copy of this report, along with appeal rights, was emailed for signature.