complaint·October 8, 2021

Allegation: Staff left resident on toilet seat for extended amount of time resulting in bruising. The Investigation Branch’s Department conducted interviews with staff from this facility, staff from various associated hospitals, medical records/reports were reviewed and found there is evidence to corroborate the allegation “staff left resident on toilet seat for extended amount of time resulting in bruising”. On 03/10/2019, medical records upon admission to Providence St. Joseph’s Medical Center revealed “reddened area on buttocks, appears as if patient was sitting on toilet for extended period of time”. Medical records upon transfer to Kaiser Permanente Panorama City revealed “DTPI (Differentiating Deep Tissue Pressure Injury) to buttocks/sacrum, posterior thighs” and “seat burn along buttocks”. Investigation Branch Department interview with staff (S1) on 06-05-2019 at 1325 hours, “staff (S1) said, at 0845 hours, (S1) went to resident (R1) room and (R1) was awake, sitting on the toilet and leaning on his right side”. Investigation Branch Department interview with staff (S2) on 06-28-2019 at 1000 hours, staff (S2) stated (S2) normally checked on resident (R1) when he was in bed, at 2230 or 2300 hours. There was no issues reported with resident (R1), on 03-09-2019, thus it did not appear staff (S2) checked on resident (R1) again, after 2230 or 2300 hours. Staff (S2) did not check on resident (R1) often because some of the residents, including (R1), did not like to be woken up by room checks. Based on LPA’s interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.