complaint·February 12, 2025

Complaint alleges that Staff is not providing oral hygiene care to resident. Based on interviews that were conducted, LPA could not prove or disprove the allegation occurred. LPA conducted an interview with a witness and learned that the facility provided care to the resident as it relates to oral hygiene. Furthermore, LPA conducted an additional interview with the Long Term Care Ombudsman (LTCO) and learned that the facility was giving the best to care for the resident even though the resident had underlying health conditions. LPA could not corroborate the allegation. Complaint alleges that Resident admitted to the hospital with unexplained broken ribs. The Departments Investigations Branch Investigator, Blatnick reviewed hospital records and conducted an interview with a facility staff member. During the interview, the Department learned that the resident fell during a transfer from the bed to the wheelchair. It is noted that the residents’ knees buckled causing the resident to fall on the floor and sustain a laceration to the forehead. Resident was subsequently transferred to the hospital where resident received three sutures and a skin tear on the left elbow. Investigator Blatnick reviewed the medical records which noted no fractures. Facility staff did not know how the resident could have sustained a broken rib. The Department could not corroborate the allegation. Complaint alleges Staff failed to seek medical attention in a timely manor resulting in resident being admitted to the hospital with sepsis. The Departments Investigations Branch Investigator, Blatnick reviewed hospital records and conducted an interview with a facility staff member. During interviews with facility staff, it was revealed that the resident was sent to the hospital immediately after showing signs of a change of condition. Investigator Blatnick reviewed the medical records which did not indicate that the resident had sepsis or severe changes in health. After the resident returned to the facility, staff at the facility noted changes but nothing that warranted a hospital visit. During observation of the resident, staff observed the resident to be less mobile and more depressed. Resident was subsequently hospitalized due to paleness of the skin and a fever. The Department could not corroborate the allegation. A finding that the complaint allegations of Staff is not providing regular showers or bathing to resident, Staff is not providing oral hygiene care to resident, Resident admitted to the hospital with unexplained broken ribs and Staff failed to seek medical attention in a timely manor resulting in resident being admitted to the hospital with sepsis are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator. During interviews with facility staff, the Department learned that the resident was admitted to the Hospital with an unstageable pressure injury on the coccyx and an unstageable pressure injury on the heal of the resident. Staff observed the pressure injury and notified the Administrator and the Residential Care Coordinator. Administrator reported this to the Primary Care Physician who in turn referred the resident to Home Health. The resident’s insurance was denied for home health. The Administrator was unable to indicate what the facility did to address the wound after the home health was denied other than putting medical honey on it and cleaning it daily. The facility did not seek any other medical options when they found out home health was being denied. During an interview with the doctor, the doctor informed Investigator Blatnick of not being aware of the residents’ pressure injuries. In addition, the doctor was never sent a fax by the facility regarding the injury. The facility provided no proof or documentation that they had notified the doctor or home health. Facility staff described the wound as “small and red” but when resident presented to the Hospital it was an unstageable wound (See LIC 9099D). Deficiencies cited from the Health and Safety Code. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in Civil Penalties. LPA advised the Administrator that the Department may seek an Enhanced Civil Penalty due to the nature of the allegation. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.