complaint·October 5, 2022

Record review revealed that R1 had been hospitalized four (4) different times between 07/07/2022 and 08/26/2022. Hospital records reviewed for the initial 07/07/2022 hospitalization did not indicate a pressure injury at the time of hospitalization or discharge from the hospital. Incident report sent to the Regional Office indicates on 08/02/2022, facility staff noticed a pressure injury on R1’s sacral area. Interviews revealed that as soon as staff noticed the pressure injury, Licensee was notified, and R1’s conservator and primary care physician (PCP) were notified. When R1’s PCP was unable to schedule a visit to observe and care for the wound timely, the Licensee sent R1 to the hospital. R1 returned from the hospital with orders for Home Health to provide pressure injury care at the facility. Home Health began to treat R1’s wound beginning on 08/13/2022, but record review revealed the wound was not staged at that time, nor was it indicated as unstageable. Wound care was conducted every other day until 08/17/2022, when facility staff again sent R1 to the hospital. Hospital records reviewed make no mention of the wound, it’s care or staging at that time. Home Health again visited R1 at the facility beginning on 08/22/2022, when every other day wound care visits resumed. R1 was hospitalized on 08/26/2022 and had yet to be discharged at the time of LPA’s initial complaint visit. On 08/29/2022, a wound consult was conducted at the hospital, where R1 had remained since their 08/26/2022 hospitalization. At the time of the wound consult, it was noted R1’s sacral wound is unstageable and measured 2cm x 2cm larger than home health indicated during their last facility visit on 08/24/2022. Wound consult notes also revealed additional wounds on both of R1’s heels that had not been previously identified during wound care prior to R1’s hospitalization. Home Health records reviewed indicate the sacral wound was getting larger in size during the time period 08/13/2022 – 08/26/2022, while Home Health was providing wound care. Additionally, hospital records reviewed for the first three (3) hospitalizations, did not indicate there was a pressure injury, and therefore did not indicate size or staging. As thus, it is unclear whether R1 sustained the pressure injury while hospitalized or while in the facility. Also, since staging was not completed during the initial Home Health consult or subsequent wound care, there is no way to ascertain whether the wound became unstageable during the course of Home Health care, at the facility, or during a hospitalization. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “Resident sustained unstageable pressure injury while in care” is deemed UNSUBSTANTIATED at this time. No deficiencies cited. Exit interview was conducted with Licensee. Report was provided via email.