complaint·September 13, 2021

However, staff prop R1’s feet up at night so that R1’s heels are dangling and not touching the bed. In addition, staff stated R2 had started to develop a pressure injury on R2’s coccyx recently but was being treated by hospice. Staff confirmed R3 may have had one pressure injury on R3’s hip or lateral thigh, but confirmed R3 had suffered a bad reaction to medication which caused R3 to turn red and make R3’s skin peel. The facility provided an opti-foam padding on R3’s mattress for extra support. A review of records on 03/12/2020, beginning at 9:30am, indicated R1 was admitted to the facility on 02/26/2019 and hospice services were initiated on 04/10/2019. Hospice notes indicate during R1’s initial assessment on 04/10/2019, wound care was performed on a stage III pressure injury measuring 5 cm X 5 cm X 0.2 cm on R1’s left heel. R2 was noted to have pressure injuries on R2’s buttocks and right ankle but receiving wound care from 12/11/2019-2/17/2020. However, hospice services were initiated for R2 on 01/13/2017. R3 was admitted to the facility on 09/25/2015 and hospice services were initiated on 04/01/2017. In summary, R1 was admitted to the facility on 02/26/2019 and a stage III pressure injury was noted on R1’s left heel during the initial assessment for hospice care on 04/10/2019. Whereas R2 and R3 sustained pressure injuries, the above-mentioned pressure injuries for R2 and R3 received appropriate care under the supervision of an appropriately skilled professional. There was no evidence to determine that R1 received appropriate wound care from either a home health or hospice agency prior to the assessment of the stage III pressure injury on 04/10/2019. A file review revealed that an exception was not filed to retain R1 in the facility with a stage III injury prior to receiving hospice care, nor did documents confirm that R1 received any wound care prior to the 04/10/2019 assessment date. Based on the investigation, there is sufficient evidence to support the claim that R1 sustained pressure injuries while in care. This allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted, today's reports and appeal rights were reviewed and issued.