complaint·October 20, 2022

Record reviews also indicate that 09/17/2021 during hospital admission, R1 was observed with an Unstageable Pressure Injury to the Let Hip / Greater Trochanter ~7.5 x 6 x 0 cm, a Stage 3 Pressure Injury to the Sacrum extending to right buttock ~6 x 6 x 0.1 cm, a Stage 2 Pressure Injury on the Left Buttock ~2 x 3 x 0 cm and Stage 1 Pressure Injuries to Right Medial Great Toe ~1 x 1 x 0 cm & Left Heel ~2 x 4 x 0 cm. On 10/27/2021 the administrator told IB that:” Around early August of 2021 R1 suffered a stroke. Unfortunately, R1 wasn't the same after this. R1 became harder to care for as R1 became more confused, physically frailer, and it became more difficult for R1 to sit or stand.“ Caregiver S1 told IB that “On 08/27/2021, R1 woke up screaming in pain when we tried to tum R1 from side to side to change R1’s diaper. After that it just got so bad that I didn't want to move or transfer R1 because R1 was in so much pain. R1 screamed when we moved them to wheelchair, turned them, any transfer that we did R1 screamed. On 09/06/2021 I noticed the pressure sores on R1’s body. I reported this to home health on 09/08/21 and they said R1 needs to go to the hospital.” Caregiver S2 stated “When R1 screamed, I didn't want to move R1 anymore, so R1 stayed in bed. On 09/06/2021 I noticed R1 developed the sores on their body. I think R1 got the sores because when we moved R1, R1 screamed, and we didn't want to cause R1 more pain, so we left R1.” Regarding the allegation “Resident developed multiple pressure injuries while in care.” Based on interviews which were conducted and the records that were reviewed by IB, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D Regarding the allegation: “Resident sustained a fracture while in care.” Record reviews conducted by IB on 10/27/2021 indicate that during hospital admission on 09/17/2021 x-ray results showed that R1 had a fracture on the right hip femoral neck. On 10/27/2021 the administrator stated:” Around early August of 2021 R1 suffered a stroke. Unfortunately, R1 wasn't the same after this. R1 became harder to care for as R1 became more confused, physically frailer, and it became more difficult for R1 to sit or stand.” Caregiver S1 stated: “It was actually on 08/26/2021 that R1 fell. R1 didn't verbalize any pain. R1 didn't have any head injuries that I could see. I did a body check and saw no cuts or bruises on their body. There was nothing that I saw that was alarming to me. I gave R1 some Tylenol and I called their family to tell them what happened. I thought R1 needed an x-ray after the next day R1 screamed. On 08/27/22021 we arranged a portable x-ray, but R1’s insurance declined it.” Caregiver S2 stated “I didn't see R1 fall because I was assisting R2 in the bathroom. S1 was in the other bathroom helping out another client.” On 11/01/2021 witness W1 stated: “This fracture occurred on 08/26/2021 and she wasn't taken here until three weeks later. The facility still should have stepped in and forced their hands because family didn't seem to know better.” Regarding the allegation: “Resident sustained a fracture while in care.” Based on interviews which were conducted and the records that were reviewed by IB, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. 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.” At this time a $500 Civil Penalty is assessed. An exit interview was conducted, plans of corrections were developed. A copy of this report and appeals rights were provided.