complaint·May 24, 2022

On 01/25/2022, between 10:15am and 12:00pm, LPA Walker conducted the initial complaint visit. The LPA met with Administrator Evelina Papazyan at 10:22am and explained the reason for the visit. The LPA conducted a physical plant tour at 10:23am, briefly spoke with staff, conducted a file review and obtained copies of pertinent documentation. The Administrator was notified that the complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Jose Santana. Investigator Santana conducted interviews with Witness #1 (W1) on 01/26/2022, at approximately 1:15pm; with the Long Term Care Ombudsman (LTCO) Region II Regional Manager on 01/27/2022, at approximately 2:00pm; with Witness #2 (W2) and R1 on 02/01/2022, from approximately 11:45m to 12:10pm; with Witness #3 (W3) on 02/09/2022, at approximately 4:00pm; with Los Angeles Police Department (LAPD) Van Nuys Station on 02/10/2022; with facility Administrator Evelina Papazyan and staff on 02/24/2022, from approximately 10:35am to 12:20pm; with CVHCare Home Health Nurse on 03/02/2022, at approximately 4:30pm; with facility staff on 03/04/2022, from approximately 3:35pm to 4:45pm; with CVHCare Home Health Nurse and Kaiser Permanente Panorama City Nurse Practitioner on 03/09/2022, from approximately 10:00am to 11:55am; with facility staff and Administrator on 03/16/2022, from approximately 1:40pm to 2:30pm; with former staff on 03/17/2022, at approximately 3:00pm; with Kaiser Permanente Case Manager on 03/29/2022; with CVHCare Home Health Nurses on 04/02/2022, from approximately 9:00am to 9:10am; and with R1’s former Primary Care Physician on 04/11/2022, at approximately 5:45pm. Additionally, Investigator Santana obtained and reviewed copies of R1’s facility records, medical records including hospital, Emergency Medical Services (EMS), CVHCare Home Health records, and photos of R1’s pressure injuries. R1’s Physician Report, dated 02/15/2020, listed the primary diagnosis as knee pain. R1 was listed as non-ambulatory with a history of backside redness and breakdown; did not have impairment of bowel and bladder; needed assistance with bathing and grooming; and was able to store and manage own medications. The Resident Appraisal, dated 03/01/2020, noted R1 as being non-ambulatory; requires the use of a wheelchair; needs assistance with activities of daily living (ADLS); can communicate clearly; is alert and oriented with no signs of confusion; likes watching tv and computer, sits in front of computer all day; and requires assistance with toileting, grooming and transferring. Continue on LIC9099C.. The Appraisal/Needs and Services Plan, dated 12/01/2020, listed R1 as needing escort assistance and help with all ADLs; fitted with a Foley catheter on 11/28/2020; alert, oriented and enjoys using computer. As of 10/04/2021, R1 had the same needs and services but now received CVHCare Home Health services for managing Foley catheter needs and skin issues. The Unusual Incident/Injury Report (UIR) submitted by the facility documented that on 10/25/2021, staff informed R1’s CVHCare Home Health nurse that R1’s wound was not healing because R1 sits in wheelchair from 6:30am to 10:00pm. The report stated that the nurse told R1 many times to lie on the bed during the day and not just sit on a wheelchair. On 10/28/2020, at approximately 12:30am, the UIR documented R1 was noted to have blood on their pull-ups, and was sent to Kaiser for wound evaluation. On 11/14/2021, at approximately 7:00pm, the UIR documented R1 was sent to Kaiser for wound evaluation due to the “wound treatment plan was not showing much progress”. On 11/18/2021, at approximately 8:00am, the UIR documented R1 was sent to Kaiser because “wounds were spotting on pull-ups, also, blood in urine…R1 sits on wheelchair for very long hours in front of computer and refuses to rest and reposition therefore the wounds bleed to the pull-ups”. R1 returned to the facility on 11/19/2021, at 6:45pm, with a diagnosis of acute hypoxemic respiratory failure and pneumonia. On 11/19/2021, at approximately 10:00am, the UIR documented the facility med tech reported to the Home Health nurse that R1’s “sore doesn’t improve, is getting worse” and explained that from 6:30am to 10:0pm, R1 sits in wheelchair playing on the computer and doesn’t want to get rest in bed. “The nurse answered me that this is the problem I have with him right now. He said he will report to his team”. On 11/20/2021, at approximately 6:15am, the UIR documented R1 called the facility office to report they were coughing up phlegm and feeling weak. R1 was transported to Kaiser. Kaiser Hospital records clarified that R1’s buttocks and coccyx pressure injuries were already at stage 3 upon R1’s 11/18/2021 admission. R1 arrived at the Kaiser Emergency Department again on 11/20/2021 at 6:41am due to chief complaint of shortness of breath and cough. R1 was diagnosed with hypoxia but was also found to have stage 3 pressure injuries of the left and right buttocks and right hip, with a deep tissue pressure injury of the left heel. Continue on LIC9099C.. R1 was admitted to Country Villa Sheraton Skilled Nursing Facility (SNF) on 11/22/2021 with a main concern of pneumonia and pressure injuries on buttocks and feet, which included stage 3 pressure injuries of the left buttock, right buttock, right hip, and sacro-coccyx, and an unstageable pressure injury of the left heel. Following wound care treatment, all of R1’s pressure injuries, with the exception of the unstageable left heel pressure injury, were resolved as of 01/05/2022. During the treatment, R1 used a low air loss mattress and was encouraged to turn and reposition every two hours. R1 was at high risk for further wound breakdown, wound infection, and slow wound healing due to complex medical diagnoses, contractures, and comorbidities. R1 completed physical therapy for the period of 11/23/2021 through 12/07/2021. On 01/07/2022, R1 was discharged to an assisted living facility with a front wheel walker, wheelchair, and a low air loss mattress. R1’s condition improved following physical and occupational therapies and medical management. R1 now required minimal assistance for transfers and was discharged with a home health referral to address pressure injury concerns, Foley catheter management, and care of other medical issues. On the allegation: Neglect/Lack of Supervision - Former facility Resident #1 (R1) developed Stage 3 pressure injuries while in care, which resulted from facility neglect: Information gathered reflected R1 moved into the facility on 03/01/2020 as a self-responsible resident. At the time of admission, R1 did not have any pressure injuries. The pressure injuries started to develop in mid-September 2021 when R1 became less mobile. R1 chose to sit in a wheelchair for hours at a time despite facility recommendations that R1 rest in bed. R1 felt pain on buttocks and believed there was probably an injury there, but it was R1’s choice to sit in a wheelchair for several consecutive hours at a time. Caregivers reported R1 sometimes declined pull-ups changes because R1 said it was too painful to be cleaned or that R1 was dry. When caregivers noted redness on R1’s buttock, CVHCare Home Health was notified and began treatment. While CVHCare Home Health documentation lists all of R1’s pressure injuries as stage 2 through 11/15/2021, Kaiser assessed them as being stage 3 upon hospital admission on 11/20/2021. These injuries were located on R1’s left buttock, right buttock, and right hip (measuring 1cm x 0.5cm), with a deep tissue pressure injury of the left heel (measuring 4cm x 3cm). R1’s skin was scaling and peeling, with areas of open skin from incontinence-associated dermatitis and areas of ulceration from pressure. Even though CVHCare Home Health declined to discuss R1’s treatment progress with the facility in spite of the facility’s requests, the facility was aware the pressure injuries were worsening and that R1 was not compliant with treatment. Continue on LIC9099C.. The facility’s response was to hospitalize R1, but failed to follow up with R1’s providers to coordinate care after discharge. Facility Administrator Evelina Papazyan claimed the facility requested a waffle/gel cushion for R1’s wheelchair to help relieve pressure, but there is no evidence from Kaiser there was any such request. Following R1’s facility departure, all of R1’s pressure injuries, with the exception of the left heel deep tissue pressure injury, healed during the course of the treatment at a skilled nursing facility despite R1’s comorbidities, showing R1’s ability to remain free of pressure injuries with adequate coordination of care. The allegation that R1 sustained Stage 3 pressure injuries as a result of the facility’s Neglect/Lack of Supervision is therefore Substantiated at this time. A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. On 01/25/2022, between 10:15am and 12:00pm, LPA Walker conducted the initial complaint visit. The LPA met with Administrator Evelina Papazyan at 10:22am and explained the reason for the visit. The LPA conducted a physical plant tour at 10:23am, briefly spoke with staff, conducted a file review and obtained copies of pertinent documentation. The Administrator was notified that the complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Jose Santana. Investigator Santana conducted interviews with Witness #1 (W1) on 01/26/2022, at approximately 1:15pm; with the Long Term Care Ombudsman (LTCO) Region II Regional Manager on 01/27/2022, at approximately 2:00pm; with Witness #2 (W2) and R1 on 02/01/2022, from approximately 11:45m to 12:10pm; with Witness #3 (W3) on 02/09/2022, at approximately 4:00pm; with Los Angeles Police Department (LAPD) Van Nuys Station on 02/10/2022; with facility Administrator Evelina Papazyan and staff on 02/24/2022, from approximately 10:35am to 12:20pm; with CVHCare Home Health Nurse on 03/02/2022, at approximately 4:30pm; with facility staff on 03/04/2022, from approximately 3:35pm to 4:45pm; with CVHCare Home Health Nurse and Kaiser Permanente Panorama City Nurse Practitioner on 03/09/2022, from approximately 10:00am to 11:55am; with facility staff and Administrator on 03/16/2022, from approximately 1:40pm to 2:30pm; with former staff on 03/17/2022, at approximately 3:00pm; with Kaiser Permanente Case Manager on 03/29/2022; with CVHCare Home Health Nurses on 04/02/2022, from approximately 9:00am to 9:10am; and with R1’s former Primary Care Physician on 04/11/2022, at approximately 5:45pm. Additionally, Investigator Santana obtained and reviewed copies of R1’s facility records, medical records including hospital, Emergency Medical Services (EMS), CVHCare Home Health records, and photos of R1’s pressure injuries. R1’s Physician Report, dated 02/15/2020, listed the primary diagnosis as knee pain. R1 was listed as non-ambulatory with a history of backside redness and breakdown; did not have impairment of bowel and bladder; needed assistance with bathing and grooming; and was able to store and manage own medications. The Resident Appraisal, dated 03/01/2020, noted R1 as being non-ambulatory; requires the use of a wheelchair; needs assistance with activities of daily living (ADLS); can communicate clearly; is alert and oriented with no signs of confusion; likes watching tv and computer, sits in front of computer all day; and requires assistance with toileting, grooming and transferring. Continue on LIC9099C.. The Appraisal/Needs and Services Plan, dated 12/01/2020, listed R1 as needing escort assistance and help with all ADLs; fitted with a Foley catheter on 11/28/2020; alert, oriented and enjoys using computer. As of 10/04/2021, R1 had the same needs and services but now received CVHCare Home Health services for managing Foley catheter needs and skin issues. The Unusual Incident/Injury Report (UIR) submitted by the facility documented that on 10/25/2021, staff informed R1’s CVHCare Home Health nurse that R1’s wound was not healing because R1 sits in wheelchair from 6:30am to 10:00pm. The report stated that the nurse told R1 many times to lie on the bed during the day and not just sit on a wheelchair. On 10/28/2020, at approximately 12:30am, the UIR documented R1 was noted to have blood on their pull-ups, and was sent to Kaiser for wound evaluation. On 11/14/2021, at approximately 7:00pm, the UIR documented R1 was sent to Kaiser for wound evaluation due to the “wound treatment plan was not showing much progress”. On 11/18/2021, at approximately 8:00am, the UIR documented R1 was sent to Kaiser because “wounds were spotting on pull-ups, also, blood in urine…R1 sits on wheelchair for very long hours in front of computer and refuses to rest and reposition therefore the wounds bleed to the pull-ups”. R1 returned to the facility on 11/19/2021, at 6:45pm, with a diagnosis of acute hypoxemic respiratory failure and pneumonia. On 11/19/2021, at approximately 10:00am, the UIR documented the facility med tech reported to the Home Health nurse that R1’s “sore doesn’t improve, is getting worse” and explained that from 6:30am to 10:0pm, R1 sits in wheelchair playing on the computer and doesn’t want to get rest in bed. “The nurse answered me that this is the problem I have with him right now. He said he will report to his team”. On 11/20/2021, at approximately 6:15am, the UIR documented R1 called the facility office to report they were coughing up phlegm and feeling weak. R1 was transported to Kaiser. Kaiser Hospital records clarified that R1’s buttocks and coccyx pressure injuries were already at stage 3 upon R1’s 11/18/2021 admission. R1 arrived at the Kaiser Emergency Department again on 11/20/2021 at 6:41am due to chief complaint of shortness of breath and cough. R1 was diagnosed with hypoxia but was also found to have stage 3 pressure injuries of the left and right buttocks and right hip, with a deep tissue pressure injury of the left heel. Continue on LIC9099C.. R1 was admitted to Country Villa Sheraton Skilled Nursing Facility (SNF) on 11/22/2021 with a main concern of pneumonia and pressure injuries on buttocks and feet, which included stage 3 pressure injuries of the left buttock, right buttock, right hip, and sacro-coccyx, and an unstageable pressure injury of the left heel. On the allegation: Neglect/Lack of Supervision - Former facility Resident #1 (R1) did not receive timely medical attention after developing stage 3 pressure injuries, and this was a result of facility neglect: Information gathered reflected R1 moved into the facility on 03/01/2020 as a self-responsible resident. The CVHCare Home Health nurse who treated R1’s pressure injuries, informed Investigator Santana that they did not communicate the plan of care or wound progress with the facility because they believed they could not share this information, given that R1 was self-responsible. The nurse further did not provide the facility with any instructions on what to do in between visits. Even if the facility had been successful in obtaining this information from CVHCare, the home health provider would have advised that R1’s pressure injuries were all at stage 2, not a prohibited health condition. The investigation did not uncover the identity of the anonymous complainant, and it is unknown how this individual learned that R1’s pressure injuries may have progressed to stage 3 weeks before 11/20/2021, but the available CVHCare documentation does not entirely support the notion that the wounds were at stage 3 prior to 11/15/2021 or that R1’s CVHCare nurse alerted facility administrator Evelina Papzyan of this. Regardless of its failure to be fully appraised of R1’s wound progress, the facility did arrange for R1 to be seen at the Emergency Department upon R1’s request several times from 10/28/2021 to 11/20/2021 because of a change in condition. The allegation the facility did not seek timely medical attention as a result of Neglect/Lack of Supervision is therefore Unsubstantiated at this time. Exit interview conducted, and a copy of this report issued.