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32 | · On 11/15/22, Hospice record review conducted. IB’s review reveal that during R1’s stay at the facility, nursing visits were made on 10/07/22, 10/12/22, 10/14/22, 10/19/22, 10/24/22, 10/28/22, 10/31/22. Client was hospitalized on 10/29/22.
· On 12/13/22, IB reviewed records from Bradman’s center, which reveal documentation of Bacterial infection prior to admission to facility. Records confirm wound care provided from 09/30/22 to 10/29/22. During Home Health Agency (HHA) visit on 10/29/22, maggots observed to R1’s toe. R1 was sent to the hospital as a result. IB’s review of records indicate that R1 continued to receive wound care services after their return from the hospital.
· On 12/13/22, IB reviewed medical records from the hospital. Record review reveal R1 arrived at the hospital on 10/29/22, and was discharged back to the facility on 11/02/22. R1 was admitted at risk for rapid decompensation due to infectious symptoms and evidence of worsening bacterial infection. On 10/31/22, treating physician recommended for surgery. On 11/02/22, Social Worker (SW) confirms R1 continued to receive daily wound care, hospice care, and weekly visits from Bradman. SW denied the maggots were due to lack of care.
· On 12/29/22, IB interviewed R1’s family who was not aware of any care concerns.
· On 01/12/23, IB interviewed the facility administrator, Jeffery Savella, Staff 1 (S1) and Staff 2 (S2).
According to the administrator, “staff are trained to observe for any obvious changes and then report to the home health nurse. As far as the administrator knows, they did not observe any such changes or issues with R1’s wound care”. Interviews with S1 and S2 confirms that they are live-in staff that helps assist with R1’s care. Both staff acknowledge R1 was receiving wound care, and they help assist the hospice nurse with the bathing and cleaning to R1, but did not see the presence of maggots to R1’s toe. Staff also indicated that their job is to visually observe for any changes between nursing visits.
Based on the information obtained by IB, R1’s conditions were chronic and existed before admission to this facility. R1 was receiving daily wound care and treatment from home health and hospice. Facility staff’s duty is to observe for any changes with R1 and report to home health, which they reported to no significant level of activity. While there was a presence of maggots to the toe area of R1, the evidence does not support that it was a result of caregiver neglect. Therefore, the allegation of staff neglect is deemed Unsubstantiated at this time. |