Allegation: Resident (R1) developed pressure injuries while in care.

On 10/10/22, R1 fell from the bed, was transferred to hospital, and diagnosed with hip fracture. R1 had hip surgery and was discharged back to the facility. R1 was followed by home health for her wound care and to remove staples from surgery. R1 developed pressure injuries while with home health care. Home Health (HH1 and HH2) provided instructions to caregivers on how to care for the pressure injuries and instructed the caregivers to elevate R1’s legs and heels so the pressure injury could heal. HH1 stated that R1 was known to refuse to be turned, refuse to have the dressings changed, and that R1 was combative towards HH1.

Interviews with staff (S3 and S4) confirmed that they were rotating R1 as directed by R1’s doctor’s and home health orders. Staff were also changing R1’s bandages in-between home health visits, when R1’s bandages became soiled or were coming off. Staff were using booties and pillows to float R1’s heels off the bed to further prevent the pressure injuries from getting bigger. An interview with facility manager, S1, revealed that staff were cleaning R1’s injures with saline solution as directed by home health to keep the wounds clean. The facility also provided R1 with booties for her heels when the equipment was not available from the home health agency.

Based on all information obtained, the allegation is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

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On 07/11/2023, a follow up interview with facility manager, S1, and caregiver, S4, revealed that the facility followed the instructions provided by the home health nurses regarding the use of pillows and booties to float R1’s feet off the bed. R1 would kick the pillows off the bed and kick the booties off. Staff would check to make sure that pillows and booties were put back on R1’s feet to prevent the pressure injuries from becoming worse. As directed by home health, the facility staff would also change R1’s bandages and clean R1’s pressure injuries with saline solution in between home health visits.

On 10/10/2022, caregiver S2 was in R2’s room and witnessed R1 fall from her bed to the floor. R1 was in extreme pain and could not stand. Other caregivers came to the room and helped S2 lift R1off of the floor and onto the bed. 9-1-1 was called and R1 taken to the hospital. It was confirmed that R1’s hip was fractured from the fall. R1 did not have any injuries or hip problems before R1 fell off the bed. R1 was not a fall risk, did not have any prior falls, was able to walk on her own with the assistance of a walker, and was not required to have two or more staff help with transfers in and out of the bed.

Two residents (R2 and R3) were interviewed on 5/31/23 who both stated they were never hurt by staff. Both stated staff check them but were not able to provide the timetable on how often they are checked.

Based on all information obtained, the allegation is unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.