complaint·September 5, 2024

Although R1's hospice agency took the hospice plan of care and binder from the facility after R1 passed, LPA was able to review Progress Notes for R1. Progress notes indicate that R1's hospice nurse indicated they would contact a wound specialist on 08/14/2024. However, interview revealed that the wound specialist did not make it to the facility before R1 passed away. An unstageable sacral wound was noted on 08/19/2024 and on 08/20/2024, R1's physician ordered "patient to be repositioned on her side every 2 hours." Interview with staff revealed that R1 was repositioned every 2 hours during the day when staff provided incontinence care. Staff indicated there was a log filled out each time they repositioned the resident. However, the hospice agency removed the log from the facility, so LPA was unable to review the document. R1's overall condition worsened and R1 passed away under hospice care on 08/22/2024. LPA attempted to contact R1's hospice agency to discuss the allegation and to obtain pertinent documents, however, LPA did not receive a response. 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 "facility staff did not follow physician's orders" is deemed UNSUBSTANTIATED at this time. No deficiencies cited. Exit interview conducted. A copy of the report was provided.