complaint·June 25, 2022

On various days from 05/14/2020 to 07/08/2020 Investigator Spindola conducted interviews with facility residents, staff, administrator and other relevant parties. Additionally, on 5/28/2020 and 6/15/2020 Investigator Spindola conducted review of Medical Records from All Saints Hospice subpoenaed on 5/14/2020 and Northridge Hospital subpoenaed on 5/12/2020. On 3/16/2022 LPA Y. Avetisyan requested Discharge Records for R1 from Casitas Care Center. The records were received on 3/23/2022. On 4/11/2022 LPA Avetisyan issued a second subpoena to All Saints Hospice to obtain complete hospice records for R1. . Records were received on 4/12/2022, 4/14/2022, 4/21/2022. Due the agency not submitting all records as requested in the subpoena LPA requested records to be prepared for pick up along with custodian of records documentation. The records were picked up on 5/22/2022 however Custodian of records confirmation was not provided. From 4/14/2022 to 4/25/2022 LPA conducted various email communication with All Saints Hospice Agency staff to clarify information documented in the records. When interviewed on 5/14/2020 and 6/15/2020 the Administrator stated that R1 was admitted to the facility on 02/20/2020 and hospitalized on 4/23/2020 due to trouble breathing. Per administrator R1 was living at the facility with hospice care after hospitalization as a result of several medical conditions including but not limited to multiple pressure injuries on back, heels, and buttocks. However, review of discharge records from Casitas Care Center did not indicate R1 having any pressure injuries. Discharge body check documented discoloration on the arms and redness on the thigh/groin. Review of hospice records revealed various inconsistencies between the documents obtained during the initial 10 day complaint visit, provided to Investigator Spindola and LPA Avetisyan. The 4/22/2020 RN visit record documented Head to toe Assessment performed. Vital signs were checked. Patient has pressures on Left Buttocks area, Mid lower back. Northridge Hospital medical records documented the following pressure injuries upon hospitalization. DTPI Left hip, Unstageable, left flank/back Upper back multiple DTPI wounds, Unstageable Sacrum-extending to bilateral buttocks , LLE skin tear with underlying hematoma vs DTPI, Unstageable Midback pressure injury, DTPI Right dorsal foot, Right medial foot and Right Posterior calf DTPI. Information obtained during the course of the investigation revealed that upon discharge from Casitas Care Center R1 did not have any medical documentation that included a diagnosis of pressure injuries. Licensee did not complete pre-placement appraisal or appraisal identifying pressure injuries upon admission. Hospice and Hospital records confirmed R1 developed multiple unstageable pressure injuries and Deep tissue pressure injuries while living at the facility therefore the allegation of Neglect/Lack of Care and Supervision is Substantiated. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.