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32 | The investigation revealed the following:
Regarding Allegation: “Staff did not prevent residents from developing multiple pressure injuries while in care.” It is alleged that facility staff did not prevent R1 from developing pressure injuries. Record reviews indicate the following: Records indicate that R1 was being provided wound care by wound care providers. Based on the hospital’s clinical findings and documentation (dated 08/01/2023), the wound was determined to be related to cellulitis and not caused by pressure injury. On 08/18/2025 and 09/06/2025 the facilities incident report indicates R1 requires wound care and has been assigned home health care. Unison Health services (dated 08/29/2025 to 11/08/2025) indicate pressure injury ulcers to left heel and sacrum. Oso home Care (dated 09/06/2025 to 12/31/2025) indicates adult failure to thrive, sepsis. Resident R1 has several pressure ulcers, chronic on his heel, sacrum, buttocks. Oso Home Care (dated 09/06/2025) wound therapy 3 times a week diagnosis of adult failure to thrive, sepsis unspecified organism. San Gabriel Valley Medical Center (dated 09/06/2025) diagnosis sepsis, diabetic mellites, schizophrenia, old stroke, wound care, unstageable to left heel, and left lateral foot, dressing every 3 days or PRN if soiled/dislodged, heel protector applies to bilateral heels, old, healed stage 2 to sacrum. First Unlimited Hospice care (09/16/2025) indicates that R1 left leg wound was cleansed with solution. Interviews revealed the following: R1 could not be interviewed due to health issues. R2-R4 deny the allegation. Staff S1 indicates Staff state that S1 staff turn the residents over every 2 hours. S1 stated that the resident had pressure injury on R1 heal and that the staff kept moving the resident. S1 indicates that home health care comes every week and treats the heal wound. S1 indicates that the pressure injuries/wound are almost healed. S1 indicates that R1 do not like to be moved and scream loudly when staff moved R1. S1 indicates that due to dementia that R1 does not like to move. (S2-S4) interviews indicate that R1 had pressure injury to left leg prior to entering the facility. Witness (W1) indicates R1 was last seen by home health on 12/31/2025 and pressure injuries were caused by diabetic issues. R1 could not be interviewed due to health issues. R2-R4 deny the allegation.
Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; "The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.” therefore, the allegation of “Staff did not prevent resident from developing multiple pressure injuries while in care” is found to be UNSUBSTANTIATED.
No deficiencies cited during today's visit.
An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Najim Shaheen (S1). |