Inspector’s narrative
What the inspector wrote
Report Continued from LIC 9099...
The initial 10-day complaint visit was conducted on 01/19/2024 by LPA B. Balisi, and subsequent visits were conducted by LPA M. Arroyo on 08/01/2024 and 10/17/2024. On 01/19/2024, LPA Balisi conducted a plant tour, interviewed staff and residents, and reviewed and obtained copies of pertinent documents at approximately 10:30 a.m. On 08/01/2024, LPA Arroyo conducted a plant tour, conducted interviews with the administrator and two staff between 10:35 a.m. and 12:15 p.m., and conducted a file review and obtained copies of pertinent documents starting at approximately 12:20 p.m. On 10/17/2024, LPA Arroyo conducted interviews with two staff and two residents between 11:25 a.m. and 12:05 p.m., and conducted a file review and obtained copies of pertinent documents at approximately 10:50 a.m. Hospice and Home Health records were also obtained and reviewed. Additionally, on 02/26/2024, Investigator Flores obtained a copy of R1’s death certificate.
Records review and interviews conducted revealed Resident #1 (R1) was admitted to the facility on 04/26/2022 and expired on 01/16/2024. R1’s physician’s report, dated 04/25/2022, listed R1’s primary diagnosis as left distal femur fracture with a secondary diagnosis of dementia and paraplegia. R1 was identified as being confused/disoriented yet able to follow basic instructions. The report indicated R1 was not able to bathe, dress/groom, care for own toileting needs, and manage own cash resources. Additionally, R1’s ambulatory status was listed as bedridden. Information obtained from the hospice records revealed that on 01/10/2024, R1’s temperature measured 100.5 degrees Fahrenheit, and on 01/11/2024, R1’s temperature had gone up to 104.7 degrees Fahrenheit. On 01/11/2024, hospice nurse administered 1000mg of Tylenol as well as apply cooling measures such as ice behind the neck on the head, by the groin, and on trunk. One (1) hour later, hospice nurse checked R1’s temperature again and it had dropped down to 102.2 degrees Fahrenheit. Hospice nurse educated caregivers to continue cooling measures and give R1 Tylenol every four (4) hours instead of six (6) hours before leaving for the day. Hospice nurse continued checking R1’s temperature every day until R1’s passing on 01/16/2024. On 01/15/2024, R1’s temperature measured 99.9 degrees Fahrenheit, and on 01/16/2024, R1’s temperature measured 98.3 degrees Fahrenheit indicating R1 no longer had a fever days before their passing. Interviews conducted with staff revealed that residents are getting all their medications as prescribed as residents have not refused their medications when administered. Staff also stated that prior to R1’s passing, R1 was eating very little as they were having difficulty swallowing and drinking.
Report Continued on LIC 9099C...
Report Continued from LIC 9099C...
Furthermore, R1’s death certificate listed R1’s cause of death as Alzheimer’s disease, vascular dementia, atherosclerosis of the aorta and hyperlipidemia. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation, “questionable death” is deemed Unsubstantiated at this time.
It was also alleged that staff did not properly care for resident’s pressure injury. It was reported that R1 had a stage 1 pressure wound on their bottom; however, on the date of R1’s death, the wound was at stage 3 as R1 was not being rotated accordingly. Per R1’s physician’s report, dated 04/25/2022, R1 had a history of skin condition or breakdown. Report also stated that R1 had a stage 2 pressure injury on right buttock upon admission to the facility. Similarly, per hospice notes, R1 was at risk for skin breakdown per Braden Scale assessment and the goal was to maintain skin integrity and be free from infection. Hospice nurse encouraged repositioning every two hours as tolerated by the resident to which the facility staff verbalized understanding. On the recertification, dated 10/06/2023, it indicated that R1 had three (3) open wounds; the first wound on the right buttock, stage 2; and two (2) more wounds on the sacrum which were a deep tissue injury and stage 2 from 08/19/2023, but were now classified as “closed” with surrounding tissue intact. Additionally, report stated that sacrum wound/skin tear had healed with no further intervention required by the nurse; however, would continue to monitor. On nurse visit, dated 10/09/2023 and 12/26/2023, wounds were assessed on R1, and hospice indicated on report that only one (1) wound remained open on the right buttock and was a stage 2. Additionally, during staff interviews, staff reported understanding and acknowledging both hospice and home health nurse advice and directions given to reposition all residents at least once every two (2) hours to prevent pressure injuries from forming or getting worst. Furthermore, interviews conducted with residents revealed that staff are constantly checking on them throughout the day. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation, “staff did not properly care for resident’s pressure injury” is deemed Unsubstantiated at this time.
Report Continued on LIC 9099C...
Report Continued from LIC 9099C...
It was further alleged that resident sustained unexplained wound while in care. It was reported that R1 had a cut on their right arm which had not been patched up and it was unknown as to how R1 had sustained the cut. Record review of R1’s physician’s report and hospice notes revealed that R1 was at risk for skin breakdown. Staff was transparent and communicated with the hospice nurse every day during their visit as displayed on visit dated 01/10/2024, which stated staff reported to hospice that R1 had a change of condition. Also, per hospice notes, dated 01/14/2024, though it confirmed that R1 had a cut on their right elbow that measured 1.8 cm which the hospice nurse cleansed, dried, and covered with drey dressing. Upon arrival of the hospice nurse, they observed R1 lying on a hospital bed in a semi fowler position, with no pain, no shortness of breath, and R1 was tolerating procedure being conducted by hospice nurse well. This indicated that R1 was most likely unaware of the cut themselves. Additionally, although staff was unable to determine where the cut on R1’s arm came from, there were no signs of abuse by staff. Furthermore, resident interviews revealed they have no concerns with staff or living at the facility. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation, “Resident sustained unexplained wound while in care” is deemed Unsubstantiated at this time.
Exit interview conducted. Report was reviewed and copy issued.
