Inspector’s narrative
What the inspector wrote
Resident sustained pressure injuries while in care.
On the allegation of ‘Resident sustained pressure injuries while in care’, it is alleged that Resident #1 (R1) was admitted to the hospital with a wound on their left heel, and a sacral stage four (4) pressure injury. To investigate this allegation, LPA Urena requested hospital records and Home Health Services records for review. On 12/08/2021, the LPA reviewed the hospital records. Hospital wound care consultation records confirmed that R1 was admitted to the Emergency Room (ER) with a sacral stage 4 pressure injury, and a left heel wound. On 07/27/2022, the LPA requested Home Health Care Services (HHCS) records and conducted the record review on 08/05/2022.
On 12/02/2021, at 12:00 p.m., the LPA interviewed the administrator about the allegations. Per the administrator, R1 started receiving Home Health Care Services (HHCS) in June 2021 due to a surgical wound. At 12:06 p.m., the LPA interviewed the Responsible Persons (RP) for R1 about the physical condition of R1. The RP reported that they knew a nurse was providing care to R1 for a surgical wound but was not aware of the pressure injury. On 07/27/2022, the LPA interviewed representatives from the HHCS agency about the care provided to R1, and the communication with the facility’s staff in regard to R1’s condition. Per the HHCS representatives, services were provided to R1 from 6/30/2021 to 11/26/2021. Services for R1 were started due a surgical wound, and not for the sacral pressure injury. Furthermore, the HHCS staff reported that the RP, and facility staff were informed of the sacral pressure injury, which developed while R1 was in care.
Continues on LIC 9099C...
The LPA conducted HHCS record review, which revealed that on 11/09/2021, HHCS staff reported that upon R1’s skin assessment, it was observed that R1 had developed ‘redness in the sacral area’. R1’s physician was informed, and per the physician’s orders, HHCS staff were to educate facility staff on the prevention of pressure injuries. HHCS record review revealed that HHCS staff instructed, and demonstrated to facility staff, the changing of R1’s position every 15 minutes (or not more than two hours), while on the bed, and sitting on the wheelchair to prevent pressure injuries. HHCS staff instructed facility staff to roll R1 to their sides to relieve pressure on the back, putting pillows in-between R1’s knees, and ankles to prevent pressure injuries when R1 was in bed. HHCS staff also instructed facility staff to assist R1 with sit-up exercises to help relieve R1’s pressure on the buttock area, while R1 was sitting on the wheelchair.
On 08/29/2022 at 10:32 a.m., staff interviews revealed that they were repositioning R1 every two hours, and as needed. Staff stated that they moved R1 from the bed to the wheelchair, and from the wheelchair to the sofa, and vice versa. Staff did not state whether they were assisting R1 with sit-up exercises. Staff stated that they ensured R1’s was kept dry by changing R1’s diaper every two hours or more often if needed.
On 11/017/2021, HHCS records review revealed that HHCS staff reported that upon R1’s skin assessment, it was observed that there was an open wound on the sacral area with a diameter of 2cm. x 3cm. The physician ordered wound care for R1. HHCS staff provided the wound care per the physician’s orders, and instructed facility staff to observe the wound, and provide wound care regimen daily.
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The LPA was concerned what type of “wound care” the staff was providing, as only appropriately skilled professionals (Licensed Vocational Nurse [LVN] or higher) are allowed to provide wound care for pressure injuries. Staff interviews revealed that they kept the wound area clean, by irrigating the wound with the cleaning solution, applying ointments around the wound area and covering the wound with a dry dressing. The administrator’s interview revealed that they were aware of the change in condition and stated that staff was instructed to only change the dressing and apply moisture cream around the sacral wound. However, since only appropriately skilled professionals are allowed to care for pressure injuries, this issue will be addressed on a case management visit.
Based on the information gathered, interviews, and records review, the resident sustained pressure injuries while in care. Although facility staff received instructions from HHCS staff on how to prevent pressure wounds, R1 developed pressure injuries, specifically in the sacral area, which started as ‘skin redness’, and progressed to a stage four (4) sacral pressure injury, and a wound on the left heel, while R1 was in care at the facility. Therefore, the allegation that ‘Resident sustained pressure injuries while in care’ is deemed SUBSTANTIATED at this time
Facility did not seek timely medical treatment for changes in resident's health.
On the allegation of ‘Facility did not seek timely medical treatment for changes in resident's health’, it is alleged that the facility staff did not seek timely medical treatment for Resident #1 (R1) when it was observed that R1’s health condition had changed; consequently, R1 developed a stage four (4) sacral pressure injury. To investigate this allegation, the LPA conducted records review and staff interviews.
Continues on LIC 9099C...
The Home Health Care Services (HHCS) record review revealed that the HHCS staff reported R1’s changes in condition on 11/09/2021 and 11/16/2021. On 11/09/2021, the HHCS staff reported that upon R1’s skin assessment, it was observed that R1 had developed ‘redness in the sacral area’. On 11/16/2021, HHCS staff reported that upon R1’s skin assessment, it was observed that there was an open wound on the sacral area with a diameter of 2cm. x 3cm. The HHCS staff provided wound care regimen per physician’s instructions. Facility staff were instructed to continue wound regimen daily. Staff interviews revealed that they kept the wound area clean by irrigating the wound with a cleaning solution, applying ointments around the wound area, and covering the wound with a dry dressing. As noted on the previous allegation, this will be addressed on a case management visit, as only appropriately skilled professionals may provide care to pressure injuries. The HHCS record review revealed that on 11/20/2021, a conversation with R1’s responsible party (RP) was held; the HHCS recommended for a wound specialist to see R1; however, the RP declined a wound specialist visit; and, any invasive wound treatment. As a result, the facility staff did not seek any further treatment for R1; though they should have elevated the HHCS concerns to the resident’s physician and sought a higher level of care for R1 versus retaining R1 in the facility with a prohibited health condition.
Based on the information gathered, and records review, the facility staff did not seek timely medical treatment for changes in resident's health. Although the HHCS staff informed the facility staff of the deterioration of the skin of the sacral area, the facility staff did not notify R1’s physician so that they further the resident in seeking timely medical treatment. As a result, the pressure injury progressed to a stage four (4) while in care. Therefore, the allegation
that the Facility did not seek timely medical treatment for changes in resident's health is deemed SUBSTANTIATED at this time.
Continues on LIC 9099C...
The following deficiencies are observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. An immediate $500 civil penalty is being assessed today.
Citations were issued. Exit interview conducted with the administrator, and signatures were obtained. A copy of the report, and Appeal Rights were issued.
