complaint·September 9, 2024

Continued from LIC 9099-A The complaint alleges that resident R1 sustained a fracture while in care. R1 was a 90-year-old female with reduced bone strength due to osteoporosis putting her at a significantly higher risk of sustaining a fracture after a fall. Interviews of the administrator and staff revealed that R1 fell sometime in early February of 2022 (specific date unknown due to lack of documentation nor report of the incident to the Department). After R1’s fall, staff did not secure immediate medical care for R1. On 2/21/2022, after R1 complained of being in “extreme pain”, the family transported R1 to the Kaiser Permanente Hospital. Kaiser Permanente medical records from 02/21/2022 show that R1 had sustained a new compression fracture of the T12 vertebrae. When interviewed, neither the administrator nor most staff members considered R1 to have a risk of falling during the 4 years she lived at the facility. The 03/17/2020 Physician’s Report did state that R1 had a risk of falling, as did the 02/21/2022 Physician’s Report after her fall. Medical records, home health records, and Kaiser Permanente Hospice records all state that R1 was at risk of falling. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099-D. A $500 immediate civil penalty is assessed today; Licensee was informed that additional civil penalties are still being determined based on Health & Safety Code 1569.49(f). Exit interview conducted and a copy of this report was provided. Continued from LIC 9099-A The complaint alleges that Resident R1 sustained a stage 4 pressure injury due to lack of care by staff. R1 developed a pressure injury on her left heel and began receiving wound care from home health. The wound eventually went away but began again within a few weeks. R1 began home health again but had two pressure injuries, one on her heel and the other on the coccyx. The wound on the coccyx got worse and R1 was placed on Hospice. The wound on R1’s coccyx continued to get worse, eventually going all the way down to the bone. R1 was receiving home health care when the stage three pressure injury on her coccyx occurred. The pressure injury continued to get worse leading to R1 being placed back on hospice care. Oakland Kaiser Hospice Site Director N1 stated that she had no concerns with the care R1 was receiving while she was at the facility. N1 also stated that the facility staff were following instructions by rotating R1 as much as they could and were doing everything, they could for R1. N1 explained that it is normal for these wounds to happen and get worse quickly when someone whose health was declining as quickly as R1’s was. Facility staff advised investigator that they saw the “red mark” on R1’s coccyx and that they notified the home health nurse of the mark. Facility staff was changing R1’s dressing on her wound every time they needed to and believed they were doing everything they could. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegation is UNSUBSTANTIATED . Exit interview conducted and a copy of this report was provided.