It was alleged that upon admission to the hospital, R1 was found with multiple pressure injuries. Prior to admission to this facility, a review of R1’s medical assessment dated 9/30/2020 and R1’s discharge paperwork from the skilled nursing facility dated 10/02/2020 did not mention wounds and/or pressure injuries outside of the healing surgical wound on R1’s left hip.

The assessment conducted by home health, dated 10/3/2020 indicated that R1 had no additional pressure injuries. However, further review of the home health notes revealed that during the 10/03/2020 initial visit, staff were allegedly provided information on ‘skin and diabetic foot care’, yet additional information was not discovered as to the staging or presence of wounds. The home health visit conducted on 10/06/2020 documented that R1 had a ‘pressure ulcer/injury’ on the left heel, right heel, and coccyx with black surrounding tissue, yet there was no information regarding staging of the wounds. Intervention notes claimed that the nurse educated facility staff on the ‘diabetic precautions and management’. The final home health visit on 10/10/2020 was documented as ‘missed’; the visit notes claimed that when home health called the facility on 10/10/2020, the caregivers claimed that they did not need another ‘teaching visit’ as it related to R1’s care. Subsequently, R1 was discharged from home health services on 10/10/2020.

The Administrator admitted that due to COVID-19, an in-person assessment was not conducted of R1 prior to R1 being admitted to the facility. Instead, the Administrator reviewed R1’s medical assessment and information from the skilled nursing facility, which neither document indicated the presence of wounds. The Administrator admitted that upon arrival to this facility, an assessment was conducted on R1 and R1 was observed to have ‘minor skin breakdowns’ on the left and right heels, and a wound on the coccyx. The Administrator was under the impression that home health would provide wound care for R1’s heels, yet the home health agency discharged R1 on 10/10/2020 and did not address the dark spots on R1’s heels. The Administrator also admitted that R1 had a ‘normal’ pressure injury on the coccyx area that was noted with redness and had started to open. The Administrator noted that R1’s heels worsened in condition, which resulted in the Administrator reaching out to R1’s primary care physician and R1’s family on approximately 10/27/2020. The Administrator reiterated that they communicated their concerns to the appropriate parties but noted that they had not received a timely response to their increasing concerns. Yet interviews with staff whom also provided care to R1 denied claims that R1 had the presence of ‘dark spots’, claimed that R1 lower body extremities were ‘good’, and appeared unaware to the fact that R1 had any wounds.

R1 was admitted to the hospital on 11/02/2020 at 5:06 p.m. due to a change of condition. Hospital admission paperwork dated 11/02/2020 indicated that R1 was admitted with a urinary tract infection, sepsis, septic shock, diabetes, end stage renal disease, hypertension, dyslipidemia, anemia, chronic kidney disease, malnutrition, hypoalbuminemia, hypokalemia, multiple pressure injuries, blindness in the left eye, and deep vein thrombosis. Furthermore, the nursing assessment conducted in the hospital revealed that R1 had a stage 4 pressure injury in the sacral-coccyx area, right heel deep tissue injury, and left heel deep tissue pressure injury. R1 was also found to have bilateral heel gangrene, and that the wounds were infected. Per the National Pressure Injury Advisory Panel, “…if necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4).” As such, due to the necrotic tissue that developed on the heels, the deep tissue pressure injuries are further noted as unstageable. On 11/04/2020, R1 had to undergo a procedure where wound debridement of necrotic tissue of the left heel was removed. On 11/07/2020, R1 passed away in the hospital. The hospital discharge summary further noted that R1 developed respiratory failure with hypoxia and that R1’s condition was deemed dire in light of multi-organ failure. The cause of death, per the Death Certificate, was noted as sepsis, urinary tract infection, diabetes, end stage renal infection.

Based on the information obtained, R1 was admitted to this facility on 10/02/2020 and assessed to have ‘discoloration’ on R1’s heels. Whereas R1 was under the care of home health, documents demonstrated that it was only for R1’s surgical wound on R1’s left hip. At the appearance of the discoloration on R1’s heels and the wound on R1’s coccyx, the staff should have sought the guidance of an appropriately skilled professional to specifically assess and treat R1’s heels. Whereas the Administrator claimed to have communicated their concern to multiple parties prior to reaching out to R1’s primary case physician on 10/26/2020, the Administrator could not provide supporting documentation or record of wounds, body checks, or logs to indicate when they consulted with home health or R1s family. The Administrator maintained the belief that R1’s dark spots were related to the diabetes, as they consulted with a home health nurse (whom was not assigned to R1) and they noted that the dark spots were likely due to R1’s diabetes diagnosis.

Exit interview conducted. A copy of the report was issue, along with appeal rights.

During interviews with the Administrator, the Administrator admitted that R1 had dark spots on their legs, feet, and heels. The Administrator communicated their dissatisfaction with the agency assigned to care for R1, as they did not address R1’s heel wounds. A review of the home health admission paperwork dated 10/03/2020 confirmed that the services was for R1’s surgical wound only and had no mention of wound care for R1’s feet. As a result, the Administrator noted that R1’s heels worsened in condition. The Administrator consulted with a home health nurse (whom was not assigned to R1) and they noted that the dark spots were likely due to R1’s diabetes diagnosis. Sill, the wounds were not monitored by an appropriately skilled professional.

Records review revealed that a tele-health visit was conducted with R1’s primary care physician on 10/27/2020, in which the Administrator requested a new home health referral to treat R1’s wounds. In addition, the Administrator advocated for R1’s feet to be elevated when R1 was at the dialysis facility, as R1 received dialysis three times a week for several hours at a time.

Hospital admission paperwork dated 11/02/2020 indicated that R1 was admitted with a urinary tract infection, sepsis, septic shock, diabetes, end stage renal disease, hypertension, dyslipidemia, anemia, chronic kidney disease, malnutrition, hypoalbuminemia, hypokalemia, multiple pressure injuries, blindness in the left eye, and deep vein thrombosis. Regarding the pressure injuries, R1 was observed to have a stage 4 pressure injury on the sacral-coccyx area upon admission to the emergency room. In addition, R1 was also found to have bilateral heel gangrene, deep tissue pressure injuries on the left and right heel, and that the wounds were infected. On 11/04/2020, R1 had to undergo a procedure where wound debridement of necrotic tissue was removed from R1’s left heel. On 11/07/2020, R1 passed away at the hospital. The hospital discharge summary further noted that R1 developed respiratory failure with hypoxia and that R1’s condition was deemed dire in light of multi-organ failure. The cause of death, per the Death Certificate, was noted as sepsis, urinary tract infection, diabetes, end stage renal infection.

Staff interviews revealed that staff were attentive in providing R1 with adequate care, which included regular body checks, providing wound care, repositioning R1, and providing R1 with a bath three times per week on average. The Administrator claimed to have cared for R1’s wounds with over-the-counter ointment and implemented additional preventative measures such as keeping R1’s legs elevated, utilizing compression socks, and regularly repositioned R1. The Administrator confirmed that at the sign of any changes, they consulted with home health, R1’s family, and R1’s primary care physician. Staff believed that R1 did not need urgent medical attention, and promptly called 9-1-1 when R1 had a change of condition.

Based on the information obtained, there is insufficient evidence to support the claim that R1 sustained an untimely death due to lack of care and supervision. Interviews with R1’s family member revealed no suspicion of neglect or lack of care from the facility staff. Due to challenges with R1’s medical insurance coverage, R1’s insurance did not cover services that R1 needed prior to being at this facility. Further review by the Department Clinical Consultation confirmed that R1 had multiple comorbidities, which placed R1 at a higher risk of decline. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Failure to provide adequate incontinent care

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.