Records review and interviews conducted revealed Resident #1 (R1) was admitted to the facility on 04/26/2022 and expired on 01/16/2024. R1’s physician’s report, dated 04/25/2022, listed R1’s primary diagnosis as left distal femur fracture with a secondary diagnosis of dementia and paraplegia. R1 was identified as being confused/disoriented yet able to follow basic instructions. The report indicated R1 was not able to bathe, dress/groom, care for own toileting needs, and manage own cash resources. Additionally, R1’s ambulatory status was listed as bedridden. Information obtained from the hospice records revealed that on 01/10/2024, R1’s temperature measured 100.5 degrees Fahrenheit, and on 01/11/2024, R1’s temperature had gone up to 104.7 degrees Fahrenheit. On 01/11/2024, hospice nurse administered 1000mg of Tylenol as well as apply cooling measures such as ice behind the neck on the head, by the groin, and on trunk. One (1) hour later, hospice nurse checked R1’s temperature again and it had dropped down to 102.2 degrees Fahrenheit. Hospice nurse educated caregivers to continue cooling measures and give R1 Tylenol every four (4) hours instead of six (6) hours before leaving for the day. Hospice nurse continued checking R1’s temperature every day until R1’s passing on 01/16/2024. On 01/15/2024, R1’s temperature measured 99.9 degrees Fahrenheit, and on 01/16/2024, R1’s temperature measured 98.3 degrees Fahrenheit indicating R1 no longer had a fever days before their passing. Interviews conducted with staff revealed that residents are getting all their medications as prescribed as residents have not refused their medications when administered. Staff also stated that prior to R1’s passing, R1 was eating very little as they were having difficulty swallowing and drinking.

Report Continued on LIC 9099C...

It was also alleged that staff did not properly care for resident’s pressure injury. It was reported that R1 had a stage 1 pressure wound on their bottom; however, on the date of R1’s death, the wound was at stage 3 as R1 was not being rotated accordingly. Per R1’s physician’s report, dated 04/25/2022, R1 had a history of skin condition or breakdown. Report also stated that R1 had a stage 2 pressure injury on right buttock upon admission to the facility. Similarly, per hospice notes, R1 was at risk for skin breakdown per Braden Scale assessment and the goal was to maintain skin integrity and be free from infection. Hospice nurse encouraged repositioning every two hours as tolerated by the resident to which the facility staff verbalized understanding. On the recertification, dated 10/06/2023, it indicated that R1 had three (3) open wounds; the first wound on the right buttock, stage 2; and two (2) more wounds on the sacrum which were a deep tissue injury and stage 2 from 08/19/2023, but were now classified as “closed” with surrounding tissue intact. Additionally, report stated that sacrum wound/skin tear had healed with no further intervention required by the nurse; however, would continue to monitor. On nurse visit, dated 10/09/2023 and 12/26/2023, wounds were assessed on R1, and hospice indicated on report that only one (1) wound remained open on the right buttock and was a stage 2. Additionally, during staff interviews, staff reported understanding and acknowledging both hospice and home health nurse advice and directions given to reposition all residents at least once every two (2) hours to prevent pressure injuries from forming or getting worst. Furthermore, interviews conducted with residents revealed that staff are constantly checking on them throughout the day. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation, “staff did not properly care for resident’s pressure injury” is deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

Exit interview conducted. Report was reviewed and copy issued.