complaint·December 19, 2022

Hospital records show R1’s wound on the right lower leg was a “gaping and deep” 6cm x 3cm. Per the paramedics, care home staff did not know when or how R1 received this wound. Interviews indicate the following: Per interview with S5, on 9/28/22 at 03:20pm S5 noticed blood coming out on R1’s right leg, S5 notified S6 that R1 had a blister that had popped. S6 provided S5 a band aid for R1's wound, S6 did not assess R1’s wound. Per interview with S4, on 09/29/22 at 05:15am S4 noticed blood on R1's leg. Administrator was notified via facetime. Administrator immediately told staff to call 911. Per interview with S6, On 10/2/22 when S6 cleaned the stitches and saw it, “it was bigger than I thought”. S6 stated, “I did not check it, that was my mistake”. Administrator stated, "Staff should have reported the wound to me right away.". S5 was given counseling and was told the protocols for incidents.Based on the Department’s interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “resident sustained an unexplained injury while in care” is found to be “Substantiated” California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Allegation: Staff did not seek medical care for resident in a timely manner. During the course of the investigation, LPA was able to find evidence supporting the allegation. It is being alleged that R1’s wound was discovered by staff sometime on the night of 9/28/22 and R1 was not brought into ER until the morning on 9/29/22. Record reviews indicate the following: On 09/29/22 at 05:00am, Administrator told staff to call 911. R1 was sent to the hospital due to a bleeding wound. Hospital records show R1’s wound on the right lower leg was a “gaping and deep” 6cm x 3cm. Interviews indicate the following: Per S5, on 9/28/22 at 03:20pm S5 noticed blood coming out on R1’s right leg. S5 notified S6 that R1 had a blister that had popped. S6 provided S5 a band aid for R1s wound, S6 did not conduct assessment of R1’s wound. Per interview with S4, on 09/29/22 at 05:15am S4 noticed blood on R1's leg. S4 called S3 and S7 to witness the wound bleeding and S7 called Administrator via facetime. Administrator told staff to call 911. On 10/2/22 when S6 cleaned R1's stitches and stated, “it was bigger than I thought”. S6 stated, “I did not check it, that was my mistake”. Administrator stated, "Staff should have reported the wound to me right away.". Based on record reviews and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “resident sustained an unexplained injury while in care” through neglect and lack of care and supervision is found to be “Substantiated” California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. A copy of this report and appeals rights were provided during the visit.