complaint·November 13, 2024

Allegation: Resident developed pressure injuries while in care. It is alleged that due to staff neglect, Resident 1 (R1) was observed with stage 3 pressure injuries. The department reviewed facility Admissions Agreement which shows that R1 was admitted to the above-mentioned facility on 06/8/2023. During admission, the facility staff conducted a skin check and noted closed wounds on the left lower buttocks area. The Department interviewed facility Administrator, Susie Fuentes, who stated that R1 did have a pressure injury, but it was within guidelines. The department reviewed Nova Vita medical records, which show that from 7/16/23 thru 11/8/23, R1 was receiving home health for skilled nursing services and physical therapy. No orders for wound care were found in Nova Vita’s records. The department reviewed facilities Resident Rotation Log for R1 for the month of October. The log has entries from 10/8/2023 to 10/29/2023 and shows sporadic notations of dates and times R1 was rotated from 10/8/2023 to 10/14/2023. The log the skips to 10/17/2023 with one entry and then again skips to 10/29/2023 with one entry. Per records from Harbor UCLA Medical Center, on 11/11/2023, R1 was admitted to the Harbor UCLA Medical Center for the chief complaint of basic life support measures, and shortness of breath. Further review of Harbor UCLA medical records indicates that on 11/12/23 R1 was found to have two pressure injuries: Stage 2 pressure injury to sacral coccyx area, and stage 3 pressure injury to right ischium. A review of facility records indicates that on a body check conducted on 10/31/2023, facility staff noted a change in condition to R1, and under pressure injury, they noted small open sore. The accompanying diagram has markings over the lower right and left ischial tuberosity. A body check conducted by Con'd on 9099-C facility staff on 11/11/2023 when R1 was transferred to Harbor UCLA Medical Center indicated R1 had a continuous sore. Further review of facility records found no indication of pressure injuries being treated by or assessed by a doctor or another licensed medical professional. The Department interviewed facility staff 1 – Staff 6 (S1-S6), and asked if R1 had any pressures injuries, of those interviewed 5 out of 6 staff were aware of pressure injury, and 2 out of 6 admitted to treating R1’s pressure injuries with A+D topical ointment. Based on records 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. Allegation: Staff did not seek medical attention to resident. The department reviewed facility Admissions Agreement which shows that R1 was admitted to the facility on 06/8/2023. Nova Vita medical records show that R1 was receiving home health service from 7/16/23 thru 11/8/23, R1 was receiving home health for skilled nursing services and physical therapy. The home health records did not show any wound care orders. A review of Nova Vita’s notes shows no indications of pressure injuries. A review of facility records indicates that on a body check conducted on 10/31/2023, facility staff noted a change in condition to R1, and under pressure injury, they noted small open sore. The accompanying diagram has markings over the lower right and left ischial tuberosity. A body check conducted by facility staff on 11/11/2023 Con'd on 9099-C indicated R1 had a continuous sore. The Department interviewed facility staff 1 – Staff 6 (S1-S6), and asked if R1 had any pressures injuries, of those interviewed 5 out of 6 staff were aware of pressure injury, and 2 out of 6 admitted to treating R1’s pressure injuries with A+D topical ointment at the direction of the facilities medical technicians(med-techs). The department conducted a further review of facility records and found no indication of pressure injuries being treated by or assessed by a doctor or another licensed medical professional from 10/31/2023 to 11/11/2023 when R1 was admitted Harbor UCLA Medical Center. The department reviewed Harbor UCLA medical records which indicate that R1 was admitted on 11/11/2023 and that on 11/12/23 R1 was found to have two pressure injuries: Stage 2 pressure injury to sacral coccyx area, and stage 3 pressure injury to right ischium. Based on records 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. Civil Penalty: An immediate $500 Civil Penalty assessed. Enhanced Civil Penalty: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was completed with Administrator Susie Fuentes, and a copy of this report was provided.