Complaint·June 3, 2022

On 01/19/2022, LPA Camara and CCLD Investigations Branch (IB) Investigator Edward Hector conducted an initial complaint investigation visit. Investigator Hector interviewed Staff 1 (S1) at approximately 1:17 p.m. and obtained pertinent records at approximately 1:35 p.m. LPA and Investigator Hector inspected R1’s room at approximately 2:03 p.m. and attempted to interview R1 at approximately 2:06 p.m. On 01/20/2022, Investigator Hector subpoenaed medical records regarding R1. On 02/16/2022, Investigator Hector received the requested medical records. On 02/16/2022 at approximately 5:33 p.m. Investigator Hector interviewed a home health nurse (HHN) who had provided care to R1. Medical records showed R1 was seen by a physician on 12/21/2021 with an open pressure injury on the left foot which was a “stage 1 or 2” pressure injury; however, the physician only prescribed one home health visit and referred R1 for a consultation with a podiatrist. On 12/29/2021, R1’s physician’s office received communication from a concerned party that R1 was not receiving adequate care. Also, on 12/29/2021, R1 was seen by a physician and during that visit treatment was started on R1’s left heel pressure injury which was said to be a “healing stage III” but “comparable to a stage 2” and an unstaged pressure injury under R1’s left breast. Home health care was ordered for two times per week 12/29/2021 – 01/15/2022. On 01/03/2022, there was a stage 2 pressure injury identified on R1’s right foot. On 01/08/2022, there was a stage 2 pressure injury identified on R1’s right Achilles’ tendon. Home health care was prescribed for two times per week and two visits as needed 01/16/2022 – 01/22/2022, then three times per week 01/23/2022 – 02/12/2022, and one visit daily 02/13/2022 – 02/19/2022. A home health nursing note dated 02/10/2022 stated R1’s “right heel has improved tremendously.” An interview with S1 revealed R1 had a stage 2 pressure injury on left heel, stage 2 pressure injury on right Achilles’ tendon, and a rash under R1’s left breast. R1’s has very sensitive skin. R1 tended to remove the heel protectors, especially during the nighttime. When staff checked on R1, they placed the protectors back on R1’s feet. R1 does not like wearing the heel protectors. R1 uses a wheelchair; however, S1 still helps R1 with daily walking exercises even though R1’s insurance has not approved further physical therapy visits. S1 also noted the staff had a difficult time getting R1 to drink more fluids, so R1’s urine would sometimes have a strong odor. R1 is able to eat independently and verbalize needs but requires assistance with all other activities of daily living. (continued on 9099-C) An interview was attempted with R1; however, R1 was difficult to understand. R1 was observed in a wheelchair being pushed by staff back to R1’s room from the activity/dining area. R1 had heel protectors on both feet. R1 appeared happy and clean. R1 responded with smiles and was pleasant when asked general questions about the care received at the facility. R1 was unable to respond to more specific or complicated questions. R1’s room was observed to be neat, clean and free of odors. During an interview with R1’s HHN, the HHN saw no signs of abuse or neglect and did not observe any unfavorable changes to R1’s pressure injuries once home health care had started. The HHN expressed surprise that R1’s right heel pressure injury healed faster than the left heel, but none of the pressure injuries worsened during the period of time R1 was receiving home health care. Based on the investigation, there is insufficient evidence to support the allegation R1 sustained unexplained pressure injuries due to a lack of care and supervision by staff. Therefore, the allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued by email.