complaint·June 1, 2022

The investigation revealed that Resident #1 (R1) was admitted to this facility on 11/12/2021. Interviews and records review revealed that R1 was discharged from a skilled nursing facility, in which R1 had recently had a stroke and was diagnosed with a stage two pressure injury. However, the pressure injury had healed. R1 was admitted to this facility with home health services for speech, occupational, and physical therapy. Interviews revealed that on 1/12/2022, R1 was visited by home health and R1 was observed with a wound on the coccyx. The wound was diagnosed as a stage two pressure injury. As such, home health requested an order for an air mattress and on 1/13/2022, home health requested an order for staff to reposition R1 every two hours. Home health requested an additional wound evaluation, yet R1’s primary care physician noted that R1 needed to be seen by their provider to determine appropriate treatment. Thereafter, the frequency of home health visits increased to approximately three times a week due to the progression of the wound. Prior to this, medical records confirmed that facility staff communicated to R1’s primary care physician that if R1’s wound was staged above a stage two, the facility would be unable to retain R1 in this facility. Thus, R1 had an appointment with their primary care physician on 1/19/2022. Interviews confirmed that staff were not immediately notified regarding the staging of R1’s pressure injury after the 1/19/2022 physician’s visit. In fact, medical records review confirmed that on 1/21/2022, facility staff sent a note to R1’s physician, requesting information regarding the staging of the wound. Thereafter, R1’s physician sent over documentation, confirming that the wound was evaluated as a ‘stage three-four pressure injury’. After receiving the documentation, the facility recognized that R1 needed a higher level of care, and R1 was sent to the emergency room on 1/21/2022. R1 was admitted to the hospital and was discharged to a skilled nursing facility on 1/22/2022 for wound care. R1 did not return to the facility. Staff claimed to have regularly repositioned R1, yet it was communicated by the majority of staff that R1 was resistant to repositioning and would oftentimes ‘return’ to an original position after being repositioned. An interview with home health confirmed that home health had no concerns regarding the care that R1 received at the facility and believed there was insufficient evidence to claim that staff failed to reposition R1, as wounds can rapidly progress within hours. CONT 9099-C Records review and interviews further confirmed that R1’s wound was regularly observed and treated by home health, and home health did not stage R1’s wound above a stage two throughout the duration of R1 residing at this facility. Once the facility received documentation that the wound had progressed to a stage three pressure injury, the facility noted that R1 needed a higher level of care and R1 was sent to the emergency room. Based on the information provided, there is insufficient evidence to support the claim that due to neglect, R1’s stage two pressure injury progressed to a stage three pressure injury while in care. R1’s pressure injury was regularly observed and assessed by an appropriately skilled professional while residing at this facility. The investigation did not reveal any suspicion of neglect or lack of care from home health or hospital staff. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued. Regarding the allegation, it was alleged that the facility failed to safeguard R1’s personal belongings, as an air mattress was ordered for R1 and R1 did not receive it in a timely manner. Interviews and records review revealed that due to R1’s stage two pressure injury, home health requested an order for an air mattress for R1 on 1/14/2022. Interviews revealed that it was delivered the evening of 1/14/2022 and that facility staff signed off for the air mattress. However, interviews revealed that although staff claimed to have signed for the mattress, staff were unable to locate the mattress after it was delivered on 1/14/2022. As a result, R1’s responsible party had to order a new air mattress for R1, and it was delivered on 1/18/2022. Upon arrival of the new mattress, the original mattress that was delivered on 1/14/2022 was found in R1’s room. Staff were unaware as to whether R1’s original mattress was always in R1’s room, or if the mattress was discovered after the 1/14/2022 and placed in R1’s room thereafter. Staff speculated that R1’s mattress was overlooked, as it was ‘rolled up’ like a sleeping bag when it was initially discovered. However, the use of the air mattress was to offset pressure on R1’s coccyx pressure injury, and due to staff oversight, R1 was without the air mattress from 1/14/2022 – 1/18/2022. Based on the information obtained, there is sufficient evidence to support the claim that staff failed to safeguard R1’s personal belongings. 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. A copy of the report and appeal rights were issued.