complaint·September 6, 2024

During the investigation the Department interviewed the reporting party (RP), staff, a witness (W1), obtained and reviewed R1’s medical records from Contra Costa Regional Medical Center. R1 was admitted to this facility from Contra Costa Regional Medical Center (CCRMC) on 10/6/2023. R1’s discharge diagnosis was major neurocognitive disorder, due to vascular disease, with mild behavioral disturbance. No pressure injuries were noted but the plan of care notes dated 10/6/2023, listed R1 as “at risk for skin impairment”. Interviews and Contra Costa Regional Medical Center records indicated that on 1/2/2024, R1 was admitted to CCRMC with a chief complaint of a wound check. R1 was assessed and was diagnosed with a stage four pressure injury on his right hip, an unstageable pressure injury on his left buttocks, a stage one pressure injury on his right knee, and a deep tissue pressure injury on his left hip and left heel. On 6/4/2024, i nterviews with facility staff (S2 and S3) stated, R1 had one pressure injury on his buttocks /coccyx area. S2 described it as a “small wound, that was kind of ope n”. S2 added that she reported this to the administrator (S1) when she saw the wound and that wound “needs treatment”. S1 was interviewed and she made inconsistent statements about what happened with R1. S1 initially stated she only saw one pressure injury on R1’s right hip, but during a follow-up interview admitted to seeing the other pressure injuries. S1 did not consider the “wounds” as pressure injuries because they were not “open” but referred as “black spots bruises”. Based on the investigation, staff did not apprise the resident’s family of the resident’s pressure injury while in care. Continued on LIC9099C. Continued from LIC9099C. During interview with W1 on 03/27/2024, it was stated that she was not aware that R1 had any pressure injuries. W1 was notified by the hospital that R1 was admitted. Furthermore, the facility did not furnish to the licensing department a report of a serious injury as determined by the attending physician and occurring while the resident was under facility supervision. This will be addressed separately on a case management visit. Deficiencies are cited under the California Code of Regulations, Title 22, Division 6, follows on LIC9099D. *A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to injury of client is pending. * Exit interview conducted. A copy of the appeal rights, LIC421M, and this report provided.