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Hollywood ALF Fined $10K for Neglect

Screen Shot 2015-07-24 at 4.06.53 PMA Hollywood assisted living facility was recently fined $10,000 by the Agency for Health Care Administration after the facility neglected to properly treat a resident’s pressure sore.

Inspection records show that a resident moved to Coolidge Palms Resort earlier this year to receive treatment for “a chronic pressure wound.” She developed the wound as a result of complications from being a bilateral amputee. While living at the facility, she repeatedly expressed concerns to caregivers that she was afraid her “sacral wound” would become re-infected because she was often left in soiled diapers. The saturated diapers would soak her wound’s dressing, after which the dressing would fall off, leaving the wound exposed.

She would attempt to clean the wound in the evening, but was unable to do so because no one was available to offer her assistance.  She told surveyors that she felt “humiliated” whenever she tried to clean the wound because there was no privacy curtain in her room.  When she finished self-treating the wound, she would re-aggravate the sore as she lifted herself from her wheelchair back into bed.  Doing so caused her “buttocks” to “drag across the bedsheets.”

An interview with the resident’s attending physician revealed that the resident’s wound had grown to a “Stage 4” pressure sore and that it “was closing very slowly.” Fortunately, the pressure sore did not show any signs of infection when the resident was examined.

Investigators also discovered that the resident’s records lacked sufficient documentation to note completion of a proper assessment, nor any “description of the sacral wound, and no “documentation of communication between the home health nurse and the facility staff.”  This communication breakdown contributed to the resident not receiving timely medical treatment.

In addition to the fine, the Agency for Health Care Administration cited the assisted living facility two Class II violations, meaning that the neglect posed a “direct threat” to the health, safety and welfare of the resident.