Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted via tele-conferencing with Administrator, Pamela Parsons. During that virtual visit, LPA Tao conducted a health and safety check and requested a copy of the Staff and Resident roster. LPA Tao virtually toured the facility via Facetime with Administrator and observed that the facility was clean and in good repair. LPA observed nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. LPA Tao observed wash basins, showers/bathtubs and toilets were operable and did not observe any immediate health and safety concerns.

On 03/05/21, a subsequent tele-visit was conducted by Investigator Jose Santana, during the visit, Investigator Santana interviewed staff from staff#1 (S1) to staff #21 (S21) which included Administrator Pamela Parsons; interviewed resident’s representative (RR); interviewed social worker (SW); obtained records from staff#9 (S9) and staff#20 (S20) to staff#23 (S23); and obtained records from police department (PD), hospital’s social worker (SW) and fire department (FD). IB reviewed resident#1 (R1)’s facility file and related documentation. Department was unable to interview resident#1 (R1) because R1 was passed away on 03/15/21.

Interviews with staff revealed that not all staff were not made aware of R1’s pressure injuries and administrator failed to communicate R1’s pressure injuries to facility staff and with R1’s home health agencies. Per file reviews, on 02/10/21, R1 had redness on buttocks. On 02/18/21,

S4 and S6 were aware of R1’s pressure injuries on resident’s back/buttock area. The facility did not address or document R1’s pressure injuries on R1’s care plan and did not notify R1’s family or responsible party of R1’s declining health and pressure injuries. On 02/25/21, S4 reported the resident had skin breakdown on resident’s hip and then notified R1’s home health care.

Administrator reported R1 was under a full medical care from R1’s home health nurses for wound care to breast and back. However, interviews with R1’s home health staff reported they provided care for R1’s existing medical condition to resident’s leg and breast, and did not provide home health services for R1’s pressure injuries to back and buttock area. Home health did not have written orders to treat R1’s pressure injuries on R1’s back and buttock area. On 02/25/21, facility staff notified R1’s home health care to evaluate resident’s back and buttock area for R1’s skin breakdown. On 02/26/21, home health reported the resident had unstageable pressure injuries on the R1’s buttock area. Therefore, as a result of staff failing to obtain timely medical attention for R1 pressure injuries, R1 physically declined and developed several pressure injuries, resulting in R1 being sent to the hospital on 02/26/21 and admitted to hospice care on 02/27/21.

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be Substantiated.