complaint·November 3, 2021

The Department investigated resident sustained multiple pressure injuries while in care. Based on record review of discharged notes, R1 was admitted to the hospital for “loss of appetite” on September 4, 2021. However, upon admission, it was noted R1 sustained multiple wounds in the following areas: heels, buttocks, lower legs, and hips. On 9/30/2021, R1 was admitted to skilled nursing facility on hospice for wound care. Staff notes indicated R1 was seen by a doctor on August 11, 2021 for the wounds on R1’s heels. R1 was referred to a podiatrist and an appointment was scheduled for September 1, 2021. However, it was cancelled due to R1 “not feeling well”. Based on interview and record review, R1 was not seen by a doctor for R1’s other wounds. Therefore, there was no doctor’s order for wound care instructions. Based on the information obtained, interviews and record reviews that the Department obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. A $500 civil penalty is assessed for violation that resulted in a serious injury. Additional civil penalties and/or Administrative Action may occur. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.