Complaint·January 3, 2024

HH started to provide wound care as of 12/18/23. However, the conditions of the wounds were not improving. During interviews with medical professionals, on 12/27/23, R1 was admitted to the emergency department (ED) at which time in addition to other health complications, R1 was presented with multiple pressure injuries, including Unstageable pressure injury on left hip. A review of the facility’s documents including the documentation completed by the HH care agency indicates that on 12/14/2023, R1 was noted with a small sore on the left thigh and redness on the right lower leg. The conditions of the injuries were not improving and R1 began receiving HH care assistance for pressure injuries on 12/18/2023. Between 12/18/23 and 12/27/23, R1’s pressure injuries were not getting better. On 12/27/24 due to health complication R1 was sent to the hospital and was presented with Unstageable and stage 3-4 pressure injuries. A review of hospital medical records received on 05/17/24 revealed that at the time of R1’s admission to the ED, R1 presented with multiple pressure injuries. A pressure injury on the left hip was staged as Unstageable and others were staged Stage 3 and 4. Based on interviews and record review, there is a sufficient information to verify that while in care of the facility, R1 developed prohibited health condition. Facility did not seek proper care and supervision and/or required incidental medical services. Therefore, the allegation is SUBSTANTIATED at this time. ---Facility did not seek medical attention in a timely manner. It was alleged that R1’s health was declining, and facility did not seek required medical attention or call 911 immediately. To investigate this allegation, on 01/03/2024, LPA requested documents at around 12:30 PM, interviewed three (03) staff from 12:45 PM – 2:15 PM and interviewed other parties at 2:30 PM. Interviews of facility staff and other medical professionals revealed that since beginning of December 2023, facility staff had noticed significant changes in R1’s physical and mental condition, however, no additional steps were taken by facility staff to seek proper medical attention until 12/27/23. On 12/27/23, R1 was transferred to the hospital after facility staff received a phone call from a medical professional, who was contacted by R1’s family member, and requested to transfer R1 to the hospital due to health decline. A review of facility documents and an incident report submitted to the Department, verified the information revealed from interviews during the investigation. Overall investigation revealed that although facility staff noted significant changes in R1’s health condition, including developing prohibited health condition, they did not seek required medical attention or attempt to seek a higher level of care in timely manner. Therefore, based on interviews and record review, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview was conducted and a copy of report was issued.