complaint·April 11, 2024

Interview with the ED and review of an incident report revealed R1 was admitted to the hospital on 04/05/2024 due to a fall. Interview with F1 revealed R1 was ready to be readmitted to the facility on 04/07/2024 but the facility refused to accept R1 back. Interviews with the ED, case worker and hospital discharge planner revealed the facility would not readmit R1 due to their unstageable pressure injury. The ED stated they arranged for two (02) different skilled nursing facilities to admit R1 so their unstageable pressure injury could heal. The ED also received medical advice supporting the skilled nursing admission from R1’s primary care physician. The ED stated that the doctor and nurses at the hospital did not find R1 suitable for admission to a skilled nursing facility and insisted R1 return to Avantgarde Senior Living of Tarzana. Review of discharge paperwork revealed R1 was admitted for “generalized weakness” and diagnosed with a “right lateral heel unstageable pressure ulcer 1x1x0 centimeters 100% eschar”. Mayo Clinic defines “eschar” as “dead tissue that eventually sloughs off healthy skin after an injury”. The hospital discharge planner clarified that the right heel pressure ulcer was “lower than a level one pressure injury”, but the nurses would not peel back the scab to measure the wound to allow it to heal. The hospital discharge planner further clarified that all wounds with healing scabs are deemed unstageable regardless of their depth, and the ED did contact the hospital for a measurement. Interview with the ED and review of the facility attendance record revealed R1 was readmitted on 04/09/2024 at 4:48 p.m. Based on interviews and record review, the facility complied with Title 22 regulations by refusing to readmit R1 due to their unstageable pressure injury. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.