Records revealed that on 4/29/21 R1 was observed by Home Health Agency (HHA) nurse to have a stage 2 pressure injury on the sacral coccyx. Charting notes from 5/13/21 indicated that R1’s left buttocks was red and tender, and the nurse provided wound care treated. On 5/14/21, chart notes indicate HHA nurse instructed the staff to apply barrier cream at every brief change but to not apply gauze or a patch and leave it open. Per the HHA notes, there was no indication of neglect on behalf of staff. A review of HHA notes did not indicate that the wound appeared above a stage 2 pressure injury. HHA notes for 5/21/21 state R1 has a small sacral excoriation and informed staff to continue to use barrier cream at each diaper change.

Simultaneously, chart notes on 5/15/21 indicate R1’s catheter continued to have leaking around the stoma/insertion point and notes to clean as needed to prevent breakdown. Between 5/15/2021 – 6/1/2021, due to frequent HH visits, R1’s catheter was regularly monitored. The 6/1/21 chart notes at 6:05pm indicated the HHA nurse changed the catheter and noted the catheter continues to leak around the surface area when flushing and in use by R1. According to the chart notes, the HHA nurse indicted they would notify the home health charge nurse to recommend R1 be seen by their primary care physician to address the ongoing issue of the catheter leaking. HHA notes from 6/1/21 indicate the catheter continues to drain around the tube and not through the tube. HHA notes state the recommendation for facility staff is to send out R1 for treatment if unstageable and the suprapubic catheter is not functioning properly and is draining around tubing not through. Hence, R1 was sent to the hospital on 6/1/21 due to foley catheter malfunction and returned to the facility the same day with special instructions recommending a wound care specialist.

Chart notes from 6/1/21 at 10:13pm indicate the resident was being discharged back to the facility. The ER doctor stated the catheter was functioning fine and recommended to follow up with a urologist. The facility chart notes also indicated that the ER doctor stated R1’s pressure wound was unstageable.

Chart notes indicated the resident returned to the facility on 6/1/21 at 11:45pm, with no new medication or treatment orders and a diagnosis of foley catheter malfunction, but was advised to follow up with urology and wound care specialist. Charting notes indicate the HHA was informed of the wound care request. Chart notes from 6/2/21 at 1:20pm indicate a HHA nurse came to reassess R1’s pressure injury on the buttocks. The HHA nurse stated R1’s pressure injury wound was unstageable. R1 was sent to the ER again due to the prohibited health condition.

Based on the information obtained during the investigation, there is insufficient evidence to support the claim that due to neglect, R1 sustained a pressure injury. R1’s care and status was regularly monitored by appropriately skilled professionals and staff kept R1’s HHA up to date regarding any changes of condition. Although R1’s catheter required attention, R1’s HHA was monitoring it and staff continued to tend to R1’s catheter within the scope of their care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time.

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