Inspector’s narrative
What the inspector wrote
Continued from LIC 9099
On 09/12/2019 and 09/16/2019, LPA conducted interviews with various personnel, including but not limited to Wound Specialist, Emergency Room (ER) nurse, and Social Worker from Northridge Hospital Medical Center. Additionally, on 09/11/2019 and 09/19/2019, interviews were conducted with various Top Choice Home Health personnel, including but not limited to Director of Nursing, Nurse Practitioner (NP) and Registered Nurse (RN). On 11/04/2019, LPA also conducted an interview with West Coast Wound and Skin personnel. Medical records were reviewed by LPA on 08/26/2019, 09/09/2019 and 09/10/2019. This case was referred to the Community Care Licensing Divisions (CCLDs) Program Clinical Consultant (PCC) for further review.
It was alleged that facility staff neglect resulted in R1 sustaining multiple pressure injuries. Information gathered and reviewed revealed that R1 was admitted to the facility on 06/18/2019. On 06/21/2019, R1 was evaluated by a Nurse Practitioner (NP) who assessed that R1 had a possible recurrent urinary tract infection (UTI), dementia, gait abnormality, was wheelchair bound and had Stage 2 pressure ulcers at left hip, right hip, right ankle along with other comorbidities. Home Health (HH) was ordered for assistance with Activities of Daily Living (ADLs) and wound management. On 06/24/2019, a Registered Nurse (RN) from HH conducted a nursing assessment and wound care to R1. Documents reflected R1 had a stage 2 pressure injury to the left hip only. Per physicians’ orders, R1 was provided wound care by HH from 06/25/2019 to 06/30/2019. However, HH documents did not reflect other pressure injuries on right hip and ankle.
R1 was transferred to Northridge Hospital due to generalized weakness, shortness of breath and cough on 06/30/2019. Per hospital records, R1 was admitted to the hospital for Sepsis and acute respiratory failure. Furthermore, the nursing assessment from the hospital indicated multiple pressure injuries as follows: bilateral hips (stage 2), right ischium (stage 1), left shoulder (stage 1), bilateral ankles (stage 1), left lateral foot (stage 1), right heel/right medial foot (stage 1), right knee (stage 2) and right buttock. On 07/08/2019, the hospital wound care consultation was conducted. Per hospital records, the family of R1 did not want R1 discharged to a skilled nursing facility (SNF). Therefore, wound care treatment was ordered and R1 was discharged back to the facility on 07/08/2019.
Continued on LIC 9099c
Continued from LIC 9099c
HH resumed its services for R1 on 7/9/2019. Per nursing assessment, the following injuries were noted: Right ankle (stage 2), left hip (stage 2), right hip (stage 2), right knee (stage 2), and right lateral foot (stage 1). R1 received wound care from HH on 07/09/2019, 07/11/2019 and 07/13/2019. Per HH records, HH nurses reported a new stage 2 pressure injury on the coccyx on 07/13/2019. R1 was further evaluated by a wound care clinic on 07/16/2019, which documented as follows: left hip acute stage 2 pressure injury; coccyx, acute full thickness skin tear; right hip, acute partial thickness skin tear; right knee, acute full thickness skin tear and right ankle, acute deep tissue pressure injury.
Information gathered revealed on 07/19/2019, R1 had a change in condition including extreme weakness and lethargy. On 07/09/2019, R1 was visited at the facility by the NP due to R1’s change in condition. Per interviews, the NP was aware of R1s pressure injuries to the left hip however, facility staff did not inform NP of the additional pressure injuries. Per the NPs expert opinion, all signs directed towards a possible wound infection therefore, Emergency Medical Services (EMS) were contacted and R1 was transported to Northridge Hospital at approximately 7:40pm. On 07/20/2019, at approximately 1:00am, R1s wounds were assessed and R1 was reported to have an unstageable pressure injury on the left 2
nd
toe, stage 2 on the right knee, stage 2 on the left inner thigh, unstageable on right lower shin, unstageable on left upper shin, stage 2 on right lateral buttock, stage 2 on coccyx, deep tissue injury on right malleolus, two (2) deep tissue injury right lateral foot, stage 1 on right achilles and unstageable on left hip. Interviews with facility staff revealed that they would put ointment on R1s wounds, if needed and would reposition every hour or two. However, based on expert opinion, it was revealed that R1s wounds on the hips significantly worsened and was possibly due to R1 not being repositioned for extended periods of time. Based on all information gathered during the course of the investigation, the above allegation, “Facility staff neglect resulted in Resident #1 (R1) sustaining multiple pressure injuries” is deemed SUBSTANTIATED at this time.
A $500 immediate civil penalty is assessed today. The licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).
Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D
Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report has been issued.
