complaint·February 2, 2024

by Department of Social Services Investigations Bureau Investigator Laura Garcia consisting of a request from home health and hospice records, records of hospitalizations, and interviews with staff 1-Staff 2(S1-S2) resident 3 (R3), Witness 1, Witness 2, Witness 4, and Witness 5 (W1, W2, W4 and W5). On 2/2/2024 LPA Shirley conducted a health and safety check and toured the facility with caregiver Nelly Salvador. The investigation revealed the following: Allegation: Staff neglect resulted in a resident sustaining multiple pressure injuries while in care It is alleged that resident had multiple pressure injuries. Investigation Branch's Department Investigator Laura Garcia conducted interviews with staff from this facility, facility residents, staff from Wound Masters wound care and reviewed medical records/reports. A review of records shows R1 resided at her own home and received hospice and home health care from Doring Care Management Services until her admittance to Comfort Home for the Elderly on 2/21/22. Investigator Laura Garcia interviewed staff from Doring Care Management (W1), who stated R1 sustained pressure injuries while under their care due to fragile skin and immobility. While at Comfort Home for Elderly, R1 received hospice services from Summer Breeze Hospice and Palliative Care and Wound Masters wound care. On 2/24/22 R1 was assessed by Wound Masters wound care services. Records from the wound care service indicate that resident had three pressure injuries upon admittance to the facility: Stage 2 to right heel, Stage 2 to left heel, Stage 4 to Sacro coccyx. Investigator Laura Garcia interviewed RN from Wound Masters, Witness 2 (W2) who stated that wounds were developed prior to R1’s move to Comfort Home for Elderly. A further review of progress notes dated from 2/24/22 to 6/14/22 from Wound Masters wound care show that by 3/17/22 pressure injury to R1’s right heel had healed. On 4/21/22 a stage 3 pressure injury was found on R1’s elbow. By 5/12/22 Stage 3 pressure injury to R1’s elbow had closed. Further review of notes by the wound care agency gives no indication of neglect by the facility. LPA Shirley spoke to staff from Wound Masters on 2/1/24, Witness 3 (W3) stated that Wound Masters staff had no concerns of neglect from facility staff. The Investigation Branch Departments Investigator Laura Garcia and LPA Shirley found there is no evidence to corroborate the allegation mentioned above. The information and evidence obtained did not sufficiently support the allegation. Con'd 9099-C Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff neglect resulted in a resident sustain multiple pressure injuries while in care” therefore the allegation is unsubstantiated. Allegation: Resident sustained an unexplained fracture while in care It is alleged that resident had a fractured hand. Investigation Branch's Department Investigator Laura Garcia conducted interviews and gathered records from staff from this facility, facility residents, home health/hospice agencies and hospitals. A review of medical reports received from UCLA Health-Medical Records show that on 1/7/22 R1 was admitted to UCLA Health for a closed fracture of the right hand. R1 was admitted to Comfort Home for Elderly on 2/21/22. A further review of records reviewed from Wound Masters wound care show no fractures sustained while R1 was under the care of Comfort Home for Elderly. Investigator Laura Garcia interviewed S1, S2, W1 and W2 regarding fractures, and all four stated the fracture did not occur while R1 resided at Comfort Home for Elderly. W1 of Doring Care Management further stated the fracture occurred under their care while R1 resided in her own home. The Investigation Branch Departments Investigator Laura Garcia found there is no evidence to corroborate the allegation mentioned above. The information and evidence obtained did not sufficiently support the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Resident sustained an unexplained fracture while in care,” therefore, the allegation is unsubstantiated. Allegation: Staff did not follow a resident’s dietary restrictions It is alleged that resident was receiving foods that were not part of her dietary plan. LPA Shirley reviewed facility records and found that the Physician’s Report dated 3/29/2022 shows that per doctor, the resident was currently on a pureed diet with thickened liquids. LPA Shirley interviewed S1, S2 and S3 and asked staff if they ever deviated from resident’s special diet. Of those interviewed, 2 out of 3 stated staff did not deviate from resident’s dietary restrictions. S3 stated that she did not work at this faciity while R1 was there, but did state that they do not deviate from special diets. Based on records review and interviews, there is not sufficient evidence to corroborate the allegation. Con'd 9099-c Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of “Staff not following a resident’s dietary restrictions,” is found to be unsubstantiated. Allegation: Facility admitted resident that needed a higher level of care It is alleged that resident was not a good fit for facility and needed a higher level of care due to needing full assistance with multiple diagnoses. LPA Shirley reviewed the facility file and found that the facility has a current and valid fire clearance for bedridden residents. A review of medical reports received from UCLA Health-Medical Records show that on 1/7/22 R1 was admitted to UCLA Health for a closed fracture of right hand, while R1 lived on her own and not under the care of the facility. LPA Felisa Shirley reviewed home health and wound care records records and found that R1 resided at her own home and received hospice and home health care from Doring Care Management Services until her admittance to Comfort Home for the Elderly on 2/21/22. Investigator Laura Garcia interviewed staff from Doring Care Management (W1), who stated R1 sustained pressure injuries while under their care due to fragile skin and immobility. When R1 entered facility on 2/21/2022, she did so with services from Summer Breeze Hospice and Palliative Care and Wound Masters wound care. A further review of files shows that the facility had a plan of care in place for resident’s care. A further review of hospice records shows that an oxygen concentrator was part of the inventory for R1, not a ventilator. With the care plan in place, the facility staff in conjunction with the various care agencies providing direct services and care to the resident, the facility did not admit or retain the resident beyond their ability to provide care. Based on records review and interviews, there is not sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of “Facility admitted resident that needed a higher level of care,” is found to be unsubstantiated. An exit interview was conducted, and a copy of the LIC 9099 report was provided to Socorro Trinidad.