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32 | According to the physician’s report dated 01/27/2021, R1 had the following diagnoses and health conditions including CHF, Aortic Stenosis, Paroxysmal Atrial Fibrillation, blindness, functional quadriplegia, had a history of skin breakdown (buttock decubiti), non-ambulatory and physical health status was listed as poor. The report also documented R1 had no capacity for self-care which indicates R1 depended on others for all activities of daily living. This is considered a prohibited health condition and will be cited on a separate report.
Records reviewed indicated R1 was admitted to the facility on 12/15/2020. Upon admission it was noted that R1 had a bed sore (pressure injury) to buttock. Facility progress notes reviewed for the time period of December 2020 through December 2021 indicate Home Health treated R1 for ongoing stage 1 and 2 pressure injuries to coccyx, buttock, and heel. The progress notes also indicate that staff were repositioning R1 frequently, as needed, and documented observations in R1’s skin condition. Dignity Home Health notes revealed the nurse performed wound care to R1’s pressure injuries and instructed staff during visits regarding pressure relieving measures.
On the allegation “Staff are not turning the resident every 2 hours” Based on the information obtained through staff interviews and facility progress notes, staff indicated they were repositioning the resident every 2 hours as per the direction of the Dignity Home Health nurses. Home Health notes reviewed indicated R1 was in a different position every time the nurse visited. Based on the information obtained, the allegation “Staff are not turning the resident every 2 hours” is deemed Unsubstantiated at this time.
On the allegation “Due to staff neglect, resident sustained a pressure injury while in care” –R1 had a history of skin breakdown/pressure injuries that were being treated by home health during R1’s stay at the facility. Staff indicated they were repositioning R1 every 2 hours as directed by the home health nurse. There was no indication or concern by the home health nurse that the staff were not following the repositioning directions. Due to the health conditions of R1, the care of R1’s pressure injuries was ongoing since the time of R1’s admission to the facility. Based on the information obtained, the allegation “Due to staff neglect, resident sustained a pressure injury while in care” is deemed Unsubstantiated at this time.
Exit interview conducted and a copy of this report issued via email and mail. |