complaint·July 13, 2022

Regarding the allegations: Resident sustained multiple injuries while in care It was alleged that upon being admitted to the hospital, R1 was admitted with pressure injuries. R1’s physician’s report dated 11/5/2021 and R1’s service plan (date unknown) did not indicate that R1 had any wounds or injuries prior to being admitted to the facility. Facility records noted that R1 was receiving home health services while residing at the facility; however, records indicated that R1 was discharged from home health services on 11/29/2021 due to lack of funding due to insurance changes. Home health records indicated that on 11/16/2021, R1 was found with a pressure injury on the heel and possibly one on the coccyx. In addition, whereas staff claim that residents are regularly repositioned as needed, there were no records or evidence to indicate whether R1 was regularly repositioned. Upon being admitted to the hospital on 12/2/2021, R1 was found with the following pressure injuries: unstageable pressure injury on the left plantar heel, stage 3 pressure injury on the left buttocks, right ear lesion, and right heel blanchable. There was no evidence of an exception to retain R1 on file, nor was R1 receiving hospice services. Based on the information obtained, there is sufficient evidence to support the claim that R1 sustained multiple injuries while in care. This allegation is deemed Substantiated at this time. Regarding the allegation: Insufficient staffing It was alleged that at the time the complaint was received, the facility had insufficient staffing due to staff being fired and/or quitting. As a result, resident care needs were let un-met. Staff interviews revealed that the licensee indeed let go of staff due to the challenges and complaints that were received from resident’s family members. Staff also claimed that management staff would step in and provide care for the residents when there were an insufficient number of caregivers or medication technicians on the floor. Yet interviews with former and current staff confirmed that there often are a lot of call-offs and admitted that resident needs could not be met. Staff confirmed that due to lack of sufficient staffing, they have not followed the care plan for Resident #4 and Resident #5 (R4, R5) both whom require two-person assist for transfers. Staff also noted that they had worked alone in the facility due to insufficient staffing. In addition, a facility file review revealed that on 12/31/2021 and 2/23/2022, Resident #6 (R6) eloped from the facility while in care due to lack of care and supervision. Based on the information obtained, there is sufficient evidence to support the claim of insufficient staffing. This allegation is deemed Substantiated at this time. Regarding the allegation: Staff did not ensure resident was adequately fed and hydrated It was alleged that upon admission to the hospital on 12/2/2021, R1 was severely dehydrated and malnourished. A review of documents indicated that R1 required assistance with feeding, as they could not feed themselves. In addition, a medication review revealed that as of 11/17/2021, R1 had a prescription to receive Ensure twice daily. However, a review of notes and staff interviews noted that R1 had not been eating for ‘several days’, reason unknown. Staff admitted that it was challenging to ensure that R1 was fed and hydrated, despite the different methods they tried. Staff claimed that R1 had stopped taking food to the mouth and staff admitted that R1 needed a higher level of care. Whereas there were no weight records to indicate R1’s weight upon admission to the facility, R1’s weight upon hospitalization on 12/2/2021 was 105 pounds. Upon discharge from the hospital, R1’s weight on 12/8/2021 was 111 pounds. Records indicated that R1 had returned to baseline and was eating while residing at the hospital. If staff felt that they were unable to ensure that R1 was adequately fed and hydrated, the facility was then unable to meet the resident need and R1 subsequently required a higher level of care. There were no records to confirm whether staff contacted R1’s physician regarding R1’s failure to thrive, and furthermore, it was the R1’s responsible party whom took R1 to the hospital. Based on the information obtained, there is sufficient evidence to support the claim that staff did not ensure resident was adequately fed and hydrated. This allegation is deemed Substantiated at this time. Regarding the allegation: Staff inadequately trained During the initial visit conducted on 12/10/2021, twelve staff files were audited to identify whether staff completed the minimum forty (40) hours of initial training. Out of the twelve files audited, four out of twelve staff had completed the minimum hours of initial training. However, three out of twelve files (Staff #2, Staff #4, Staff #5) had insufficient training hours completed, and five out of twelve staff (Staff #6, Staff #7, Staff #8, Staff #9, Staff #10) did not have a transcript or training hours available at the time of the visit. Interviews confirmed that the training transcripts were the only available documents to confirm completed training hours. Staff interviews confirmed that at the time of the visit, the Executive Director was tasked with updating staff and resident files, and understood that many staff were deficient in their training hours. Based on the information obtained through the course of the investigation, there is sufficient evidence to support the claim that staff were inadequately trained. This allegation is deemed Substantiated at this time. Regarding the allegation: Staff failed to reposition the resident It was alleged that staff failed to reposition the resident, which aided in the development of pressure injuries. Records review indicated that R1 was either bed-bound or in their wheelchair. Records also noted that R1 was unable to reposition themselves. Interviews confirmed that whereas staff do not keep repositioning logs, former and current staff claimed that they reposition residents every two hours. Unfortunately, were no facility records to show staff had a schedule to frequently check R1 for incontinence care or repositioning. In addition, staff stated that most residents are out of bed and are congregating in common spaces. Consequently, interviews with former staff and record review confirmed that R1 had developed a pressure injury on the heels and that they had provided wound care. Home health records indicated that on 11/16/2021, R1 was found with a pressure injury on the heel and the coccyx.. Upon being admitted to the hospital on 12/2/2021, R1 was found with the following pressure injuries: unstageable pressure injury on the left plantar heel, stage 3 pressure injury on the left buttocks, right ear lesion, and right heel blanchable. Hospital records review indicated that R1 required maximum assistance due to poor mobility, and noted that R1 was cooperative with care and turning. Based on the information obtained, there is sufficient evidence to support the claim that staff failed to reposition the resident, which aided in the development of pressure injuries. This allegation is deemed Substantiated at this time. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. Exit interview conducted. A copy of the report was issue, along with appeal rights.