Complaint·June 19, 2022

(continued from LIC 9099) IB Investigator Vasquez interview with the nurse on 08/26/21 at about 2:30 PM, revealed that the nurse discovered R1 to have unstageable ulcers on left heel and coccyx area, the nurse added that R1 was not in hospice care nor there is a prior hospice care or home health services for R1. The nurse referred R1 to hospice care but the family member of R1 refused. Further interview with the nurse also revealed that the facility did not inform the palliative care agency nor the hospital to inform of R1’s pressure sore condition prior to or immediately after the nurse’s visit on 08/04/21. It was only on 08/09/21 that the facility brought R1 to the hospital without being treated at the facility. Investigator Zertuche’s interview with the administrator on 09/16/21 at around 12:00 PM, revealed that R1 was not brought to the hospital nor the facility contracted a hospice agency to care for R1’s wound because R1’s family member refused to do so. Moreover, Investigator Zertuche’s interview with two (2) care staff on 09/16/21 at 12:30 PM and 1:00 PM respectively, revealed that R1 was not being checked and/or changed diapers regularly, especially during nights. Investigator Zertuche’s medical record review on 08/26/21 at around 5:00 PM revealed that R1 had stage 3 pressure sore on coccyx and unstageable pressure sore on left heel. Based on the information gathered during the course of the investigation, including interviews, and record review between 08/26/21 and 09/16/21, R1 developed pressure sore (Unstageable and Stage 3 pressure injuries) while in care. Therefore, the allegation is deemed substantiated at this time Citation issued, appeal rights discussed and given. Exit interview conducted and report issued.