complaint·March 2, 2023

On 11/18/2022, between 9:41am and 10:30am, Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced initial complaint investigation visit at the facility. LPA Camara met with Facility Manager Joey Vitug and explained the reason for the visit. During the visit, the LPA obtained pertinent records at approximately 9:56am to10:15am. The LPA noted further investigation was required prior to issuing findings. Investigator Slatic conducted interviews on 12/29/2022, at approximately 1:44pm, with a wound care case manager/Registered Nurse; and on 02/09/2023, from approximately 11:20am to 1:00pm, with the Executive Director and R1. In addition, the investigator reviewed the hospital medical records, the Kaiser (wound center) medical records, photos of wounds and facility file documents related to R1. According to the resident’s medical records, R1 was taking blood thinner medication requiring regular INR (International Normalized Ratio) testing (to measure the time for the blood to clot). R1 visited an Infusion Center for wound care on 07/27/2022. Treatment was provided to a wound on R1’s left leg, reportedly caused by hitting the area on R1’s wheelchair. An order was given for weekly wound care treatment. On 08/03/2022, there was charting of a wound on the right buttocks area when R1 came in for treatment of the leg wound. A telehealth visit was conducted on 09/07/2022 to attempt to arrange for a home health nurse to come to R1 for the buttocks wound care. However, R1 refused the home health referral stating they did not like home health and preferred to come in person to the wound center. R1 attended the wound care center on 09/27/2022. The buttock wound and lower extremity wounds were treated. The wounds were noted to be “progressing well”. On 10/05/2022 and 10/12/2022, the wound was noted to be stable and progressing slowly. R1 phoned the wound center on 10/17/2022 to advise they hit their head the day before but was cleared for head trauma after going to the hospital. R1 was diagnosed with a urinary tract infection (UTI). The wound center advised R1 to monitor self for signs and symptoms of unusual bruising, bleeding and stroke. On 10/17/2022, at 12:50pm, a Nurse Practitioner came to the facility to examine R1. This was a six-month visit as part of the facility based primary care program. The notes indicate R1 is alert and oriented to person, place and time. R1 uses a wheelchair but is able to toilet and transfer self without assistance; and, is independent in basic activities of daily living (ADLs). The nurse noted a “small right butt ulcer covered with foam dressing”. Continues on LIC 9099C... The heels were intact but many bruises, skin tears and abrasions were observed on R1’s legs noted to be managed by home health. By that evening, R1 had returned to the hospital after being advised that R1’s head CT scan from the previous day showed possible internal trauma. R1 requested that staff arrange for transportation to go to the hospital as ordered by R1’s doctor. This type of event was typically the way R1 handled routine appointments. R1 did not give staff any further details and staff did not press R1 for more information. A review of the hospital medical records indicate R1 went to the Emergency Room (ER) on 10/16/2022 reporting they had a fall and hit their head. A neurology consult note stated R1 slipped or fell out of bed and hit the right side of their head. R1 is on the blood thinner, Coumadin. R1 had a CT scan which showed no acute abnormality, and R1 was released. On 10/17/2022, the same treating physician was looking again at the radiologist’s readings. It stated that there was a possible subdural hematoma. The Dr. called R1 to advise R1 to return for another CT scan and have their INR tested. R1 complained of a headache but denied other symptoms. R1 returned to the hospital on 10/17/2022. A follow-up CT scan was inconclusive, but an MRI showed subacute subdural hematomas about the bilateral frontal lobes. R1’s INR had increased to 4.3 and R1 had a skin tear/contusion on left arm. After consultation between the hospital and the wound center’s physicians, it was decided to admit R1 to the hospital for further evaluation. A wound consult was done on 10/18/2022 at 4:00pm. It noted bilateral lower extremities with skin tears in different stages of healing; a left shoulder partial to full thickness skin loss in scattered areas with scant serosanguineous drainage, no odor; a Stage 2 pressure injury on right ischial area (lower part of hip bone) measuring 2cm x 2cm; a community acquired deep tissue pressure injury on R1’s sacrococcyx area measuring 3cm x 3cm was described as “maroon non-blanchable discoloration, no drainage or odor.” On 11/01/2022, R1 was sent to a skilled nursing facility for rehabilitation due to unsteady gait and difficulty ambulating. Upon admission, R1 was found to have a sacrococcyx wound that was community acquired, which measured 2.7cm x 1.5cm and was unstageable. Continues on LIC 9099C... During the course of the investigation, it was revealed that R1 was being treated for a wound to their right buttock area since at least 07/27/2022. Records show that R1 declined to have a home health nurse come to the facility to provide treatment and instead chose to have the wound care done weekly at a wound center. During the last visit to the wound center on 10/12/2022, the wound was noted to be stable and progressing slowly. A wound center nurse examined R1 at the facility on 10/17/2022 and noted a “small right butt ulcer covered with foam dressing.” The unstageable condition of the pressure injury was not observed until 11/01/2022, two weeks after R1 left the facility to the skilled nursing facility for rehabilitation. R1 stated that they are a private person and did not report the wound to facility staff. R1 preferred to manage the condition by their self as a retired nurse and seek their own wound care. The Executive Director was not aware of the wound. R1 is highly independent and does not need help with any ADLs. For this reason, caregivers did not have an opportunity to observe any skin integrity issues. Though R1 sustained the unexplained pressure injury while living at the facility, it was not due to staff neglect. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the allegation. Therefore, the allegation “Neglect/Lack of Supervision: Resident #1 (R1) sustained an unexplained unstageable pressure injury while in care” is deemed Unsubstantiated at this time. Exit interview conducted, a copy of this report issued.