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32 | {9099-C-2}
The care plan for R1, written by Administrator Grace Quierez, noted that primary care staff will be instructed maintain proper medication, encourage resident for daily activities and range of motion, in addition to “Instruct facility staff and primary caregiver to observe patients’ skin during bathing and toileting”, and position pillows to prevent pressure and skin to skin contact.
Per record review and interviews, a review of the Preplacement Appraisal dated 8/20/2023 for R1 indicates 2-person assist is needed for bathing, and toileting. Facility was unable to show they repositioned R1 on a regular basis and there was no plan in place to ensure residents are rotated and checked for developing pressure injuries. Medical records show R1’s wounds got worse overtime, and necessary medical attention was not obtained. R1’s primary cause of death is septic shock due to stage 4 pressure wounds. It was corroborated by S1, S3, and S4 that care staff did not notify the Licensee or Administrator when the pressure injuries were noticed nor did they activate 911. Facility did not ensure staff were properly trained in Pressure Injuries. Per interviews and record reviews, it was learned that S3 noticed R1’s pressure injuries on 08/26/2025 and attempted to clean the wounds themselves prior to notifying the Licensee on 8/28/25. S4 was also aware that R1 had developed pressure injuries prior to 8/28/25 Per, R1s Personal Rights for RCFE dated 08/26/2025, Gene-Lyn Guest Home, Inc. must provide continuous care and supervision and if there are any changes in R1’s physical, mental, emotional, and social functions, the facility must notify the resident’s family, physician, and other appropriate people.
A hospital physician (W1) explained that the pressure injuries could have developed over the course of a few days, but not in a single day. This suggests that the injuries likely developed during R1’s residency at Gene-Lyn Guest Home, Inc. Interview with a Witness 2 (W2), revealed that upon R1’s hospitalization, R1 was found to have multiple pressure injuries. W2 stated that some gauze in R1’s lower back wound, they stated It “...seemed like someone was trying to clean the wound but was inexperienced”. A review of R1’s medical records obtained from the hospital confirmed the presence of multiple pressure injuries that had developed for “weeks” leading up to R1’s death on 9/1/25 and the primary cause of death was stage 4 pressure injury ulcers. Based on the above noted information, the allegation that a “Resident developed multiple pressure injuries due to neglect by staff” is substantiated.
{Continued on 9099-C-3} |