complaint·January 31, 2023

Resident developed a pressure injury while in care – SUBSTANTIATED On 8-25-2022, R1 was noted to have a "blister" on their tail bone. Enloe Home Health was notified of the blister. On 9-03-2022, the blister popped, and a liquid came out. Enloe Home Health was notified. On 9-09-2022, Enloe Home Health diagnosed the blister as a stage 2 pressure ulcer. Staff was advised to keep the ulcer clean and covered. On 9-15- 2022, R1 had a follow up appointment and the ulcer was re-classified as a stage 4 ulcer. R1 is non-ambulatory and relies on staff to transfer them in and out of bed. According to staff, R1 wakes up around 0630 hours and is placed in their wheelchair until around noon, when they are placed back in bed for an hour to take a nap. R1 is taken out of bed and placed back into their wheelchair until 1930 hours when R1 spends the remainder of the night in bed. Staff advised that R1 can rotate themself if needed, but staff rotates R1 three times a night. R1 advised staff allow them to sit in a dirty diaper during the night. Staff advised R1 does not soil their diaper during the night and if they do, its "only a little wet" and R1 is left in the little wet diaper. Facility staff were advised by Enloe Home Health to keep R1 off of their pressure ulcer and rotate R1 every two hours. The facility Administrator Kristine Abejo advised due to R1 wearing hearing aids, staff could not rotate R1. Enloe Home Health advised staff to keep R1's pressure ulcer clean and covered. Abejo advised R1 did not have a pressure ulcer, but the infected area was an infection. Abejo advised she could not follow Enloe's Home Health care orders or else R1 could have died. Note: Abejo is not a nurse nor does she have any medical training to make this assumption. Abejo freely admitted to not following Enloe's Home Health orders. Enloe Home Health staff, Rachel Zanon, Vashty Kyle, and Corinne Richter all advised that Abejo directly informed them she was not going to follow the care instructions given by Enloe Home Health. Due to R1 sitting in their wheelchair all day, not being rotated at night, and Abejo failing to follow the care directions from Enloe Home Health, R1's pressure ulcer developed from a stage 2 ulcer to a stage 4 ulcer. The allegation of Neglect/Lack of Care and Supervision is substantiated due to staff failing to properly care for R1 and going against medical professionals' care instructions. Continued on LIC9099-C Staff are not following treatment plan as prescribed for resident - SUBSTANTIATED During interviews the licensee stated she could not follow Enloe's Home Health care orders or else R1 could have died. The licensee freely admitted to not following Enloe's Home Health orders. Enloe Home Health staff, Rachel Zanon, Vashty Kyle, and Corinne Richter all advised that the licensee directly informed them she was not going to follow the care instructions given by Enloe Home Health. Based on interviews the department has conducted this allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to licensee Kristine Abejo. As a result of the resident sustaining a stage 4 pressure injury, an immediate civil penalty was assessed in the amount of $500.00 on 01/31/2023, on the attached LIC421IM. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Continued on LIC9099-D