complaint·December 15, 2023

On 03/05/21, a subsequent tele-visit was conducted by Investigator Jose Santana, during the visit, Investigator Santana interviewed staff from staff#1 (S1) to staff #21 (S21) which included Administrator Pamela Parsons; interviewed resident’s representative (RR); interviewed social worker (SW); obtained records from staff#9 (S9) and staff#20 (S20) to staff#23 (S23); and obtained records from police department (PD), hospital’s social worker (SW) and fire department (FD). IB reviewed resident#1 (R1)’s facility file and related documentation. Department was unable to interview resident#1 (R1) because R1 was passed away on 03/15/21. Regarding allegation: Resident sustained multiple severe pressure injuries while in care. It was alleged that a resident had multiple pressure injuries from resident’s leg, back and buttock area while in care. During the investigation, the department interviewed staff (S1) through (S21), reviewed R1’s facility file and reviewed documentation from outside providers. Per staff interviews, R1’s home health representative indicated they were not aware of R1 pressure injuries, were not notified by the facility of R1’s pressure injuries and did not receive any orders to treat R1’s pressure injuries. Home health staff were notified by the facility of R1s pressure injuries on 02/25/21. Interviews with staff revealed that not all staff were not made aware of R1’s pressure injuries and administrator failed to communicate R1’s pressure injuries to facility staff and with R1’s home health agencies. Per file reviews, on 02/10/21, R1 had redness on buttocks. On 02/18/21, S4 and S6 were aware of R1’s pressure injuries on resident’s back/buttock area. The facility did not address or document R1’s pressure injuries on R1’s care plan and did not notify R1’s family or responsible party of R1’s declining health and pressure injuries. On 02/25/21, S4 reported the resident had skin breakdown on resident’s hip and then notified R1’s home health care. On 02/26/21, the home health nurse came to assess R1 for pressure injuries and reported R1’s had unstageable pressure injuries on the resident’s back/buttock area and left heel. Although the facility contacted home health on 02/19/21, a home health assessment of R1’s pressure injuries was not obtained until 02/25/21. Thus, R1 developed multiple severe pressure injuries, an unstageable pressure injury to the back, buttock area and left heel, due to staff failing to address R1 pressure injuries in R1’s care plan and did not obtain home health for R1s pressure injuries upon first knowledge of R1s pressure injuries on 02/18/21. Regarding allegation: staff did not seek medical attention for resident in a timely manner. It was alleged that facility staff failed to provide timely medical care to resident who had several pressure injuries, including unstageable pressure injuries. The department interviewed staff (S1) through (S21), reviewed R1’s facility file and reviewed documentation from third party providers. (Report Continued on LIC9099-C...) Staff, S4 and S6, observed R1 had pressure injuries on 02/18/21. Per administrator, staff had been performing medical treatment to resident’s wound care on the pressure injuries since the wounds were first observed on 02/18/21. Per R1s records review, there were no documents or written orders to reflect the facility obtained medical treatment for R1. Administrator reported R1 was under a full medical care from R1s home health nurses for wound care to breast and back. However, interviews with R1’s home health staff reported they provided care for R1’s existing medical condition to resident’s leg and breast, and did not provide home health services for R1’s pressure injuries to back and buttock area. Home health did not have written orders to treat R1’s pressure injuries on R1’s back and buttock area. On 02/25/21, facility staff notified R1s home health care to evaluate resident’s back and buttock area for R1’s skin breakdown. On 02/26/21, home health reported the resident had unstageable pressure injuries on the R1’s buttock area. Therefore, as a result of staff failing to obtain timely medical attention for R1 pressure injuries, R1 physically declined and developed several pressure injuries, resulting in R1 being sent to the hospital on 02/26/21 and admitted to hospice care on 02/27/21. Regarding allegation: Staff did not notify resident's authorized representative of change in resident's condition. It was alleged that staff did not inform resident’s family/authorized representative about the resident’s pressure injuries, ongoing physical decline, and the tremendous weight loss. Per staff interviews, staff were aware of R1 had pressure injuries on 02/18/21 which were reported to staff internally and on 02/25/21, R1 had skin breakdown which staff reported to home health. On 02/26/21, R1’s authorized representative was notified by R1’s home health representative that R1 had unstageable pressure injuries and the ongoing physical decline. Per staff interview, S6 admitted to knowledge of R1 having a change of condition on 02/18/21, however, staff did not inform R1’s representative about R1’s change in condition. During LPA Tao’s 12/08/23 telephone interview with administrator, the administrator admitted that facility only reported R1s change in condition internally within the facility and did not notify R1s family or representative. Thus, staff failed to inform resident’s authorized representative regarding R1s change of condition. Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC9099-D. (Report continued on LIC9099-C...) An immediate $500 civil penalty is being issued during today's visit due to the lack of care and supervision resulting in resident sustaining multiple pressure injuries. The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). An exit interview was conducted and a copy of the licensing report, along with appeal rights were provided to (Staff Name & Job Title).