Other·December 16, 2021

Regarding Allegation #1 : this investigation revealed that upon admission to the facility on 08/25/19, the physician’s report (dated 08/01/19) documented that Resident #1 (referred to as R1) had a history of skin condition/breakdown. Medical records (dated 08/26/19) noted a physical examination was performed on Resident #1 for pressure injuries present during hospital admission: right toe – Stage 2; Right heel – Stage 3 without surrounding erythema or purulence; severe Sepsis with acute organ dysfunction, non-traumatic acute kidney injury, BPH with urinary retention, Dementia, severe protein calorie malnutrition, venous statis edema with ulcer. Home health agency records (dated 08/26/19) documented that Resident #1 was referred to ComCare Home Health (an affiliate of Kaiser Permanente Medical Group) and was first seen by one of the on-site home health agency nurses on 08/29/19 for start of care. Home Health RN noted multiple wound locations: Unstageable pressure injuries on the left and right buttock/ open-skin injury on right toe, and open Stage 2 pressure injury on right heel. All wounds were reported to physician and coordinated to facility staff. ComCare Home Health Skilled Nurse (Florence Atena) instructed PCG’s in pressure management and prevention; of which, facility staff verbalized understanding. Medical records (dated 09/28/19) revealed that Resident #1 was hospitalized due to severe sepsis and was discharged back to the facility on 10/03/19. Resident #1 had wounds on: left heel – unstageable pressure injury; right heel – open Stage 2 pressure injury, measuring 3x3x0cm; right great toe – open skin injury, measuring 1x0.5x0cm; left buttock – unstageable . ComCare Home Health received the order (dated 10/04/19) to resume home health care to Resident #1. Staff #1 told ComCare Home Health Skilled Nurse, Florence Atena (on 10/11/19) that he had performed wound care on Resident #1’s sacrococcyx and did not allow Skilled Nurse Atena to turn Resident #1 (again) to check the wound. Skilled Nurse Atena documented and reported Resident #1’s health and behavioral condition. Based on Skilled Nurse Atena’s observations, it was believed that Resident #1 required a higher level of care. Skilled Nurse Atena continued daily wound care visits for Resident #1 and foley catheter change on 10/16/19. On 10/23/19, upon re-cert visit, Home Health RN, noted an unstageable pressure ulcer on Resident #1’s left hip and reported to medical doctor about the new wounds and recommended wound care treatment. On 11/06/19, Resident #1 was hospitalized due to a septic shock, dehydration, and pressure injuries. Resident #1 expired on 12/04/19. Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation NEGLECT/LACK OF SUPERVISION: Severe neglect resulting in resident developing a pressure injury is found to be SUBSTANTIATED. Regarding Allegation #2 : this investigation revealed that on 10/23/19, it was determined that Resident (#1) (referred to as R1) was diagnosed with the following pressure injuries: Wound 1 – right heel (measured 6.7 x 6.5 cm); Wound 2 – left heel (measured 3.5 x 3.2 cm); Wound 3 – left hip (measured 10.4 x 6.7 cm); Wound 4 – right hallux, no odor, no drainage, wound bed appearance necrotic; Wound 5 – bilateral buttocks with moderate serosanguineous drainage, yellow wound bed appearance. ComCare Home Health instructions to facility staff were to keep these areas dry and clean as well as keeping pressure off by elevating and rotating Resident #1 regularly. A review of Resident #1’s “ Needs and Services Plan ” (dated 08/25/19) did not document information about potential pressure injuries or change in condition prior to the Resident #1’s hospitalization on 09/28/19. Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation NEGLECT/LACK OF SUPERVISION: Facility failed to address resident's change in medical condition is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency observed and citation issued (ref. LIC 9099D) – civil penalty will be assessed. 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 conducted and copy of the Complaint Report and Appeal Rights were provided to Administrators Sherryl Rafols and Mark Loo.