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32 | Per S1, they only saw a line on R1’s backside and stated although they did not document, they would reposition R1 every two hours. During their interview, S2 stated R1 had been receiving home health services and stated they did not know why these services were terminated and had contacted the Home Health agency and had been informed all visits were completed, and they would have to contact R1’s SP. Per S2, R1 was without home health for approximately three weeks (September 11, 2025 through September 25, 2025), however, S2 stated several Social Workers (SWs) would come to visit and in September 2025, R1 did not have any wounds. S2 stated the only issue had been with R1’s feet and the podiatrist prescribed “booties” which caused R1 to sustain a crease on their leg. Per S2, the crease was not open but was “black and blue.” S2 stated they had photographed it, however, was unable to provide the Department with the photograph. S2 stated that by the beginning of October 2025, the wound became a laceration which did open, and a wound nurse began treating it on September 29, 2026. Per S2, they were instructed by the nurse not to agitate or treat the injury. S2 stated they provided a sponge bath to R1 every week and they made sure the laceration dressing was kept dry and that the injury was always bandaged, and neither S2, nor other facility staff visibly saw the injury. S2 stated they had no reason to think R1 was in any immediate danger because R1 was eating well, and they saw no grimace regarding the crease wound.
During their interview, W1, a Social Worker, stated they conducted a visit on September 29, 2025, to the facility and observed a blackened sore on R1’s right heel and noted a cotton wrap around R1’s left calf. Per W1, S1 stated R1 had “tiny, small sores” on their back and a worsening sore on their heel and reported that a podiatrist had recommended a heel protector, which was applied on September 16, 2025, however, by September 17, 2025, the heel sore had worsened. Per W1, R1’s SP was not informed of the sores until September 26, 2025, nine days after the initial observation. W1 confirmed that had been a lapse in home health services for approximately three weeks as R1’s SP does not have its own staff to check on R1 weekly, therefore, a SW would conduct a visit periodically, and a home health care nurse would visit two times a month. Per W1, an air mattress was ordered by R1’s SP to alleviate the pressure of the pressure injuries and when they inquired about the low-air-loss mattress and Hoyer lift, which had also been ordered by R1’s SP, S1 informed them the mattress had been returned because R1 "did not like it” and S1 was unsure whether the current Hoyer lift belonged to R1. W1 confirmed that the air loss mattress was transported and delivered on July 2, 2025, and the facility declined to receive it, although they signed for it, and the Hoyer lift had been provided to assist with transfers. Per W1, the Hoyer lift was not utilized as R1 had not been out of bed for two months and stated facility staff have been educated multiple times to inform R1’s SP of health changes. (Cont. LIC9099-C) |