complaint·May 27, 2022

Regarding the allegation, ‘Resident sustained pressure injury while in care,’ it is alleged that R1 sustained pressure injurie(s) while in care. According to the complainant, on 9/6/2021, R1 was seen by a Home Health Medical Team (HHMT) and had a small opened wound. Then on 9/21/2021, the HHMT saw R1, and the images showed an “unstageable” pressure injury (most severe). During the investigation, the LPA attempted to contact R1 to obtain additional information. However, all contact numbers provided were no longer in service. The investigation revealed that R1 was admitted to this facility on 9/10/2021. A review of the initial Physician’s Report, dated 9/9/2021, indicated that R1 did not have a history of skin breakdown. The reporting party was able to interview R1, who informed them that there were only two little ladies working the facility, who were physically unable to move or reposition R1. On 9/28/2021, R1 went to the Hospital for a Radiology appointment. During the appointment, R1 reported having a painful pressure injury on R1’s sacrum. The nurse then requested that Radiology send R1 to the Emergency Room (ER) to get care “for stage 4 pressure ulcer.” Record review revealed that upon admission to the ER, R1 was assessed by a wound care RN, in which the nurse documented “Type of Wound: pressure injury. Location: Sacro coccyx. Stage: Unstageable. Measurements(cm): 11x11 x0.1 cm (uneven edges) ...” Records review revealed that R1 was discharged from the hospital on 10/13/2021 with palliative care to a Skilled Nurse Facility (SNF). Record review revealed that R1’s home health admission date was 9/13/2021. An interview with the administrator revealed that R1 was only at the facility for 19 days; R1 went to a radiology appointment and was then transferred to a SNF. According to the administrator, they were unaware of the severity of R1’s skin integrity. The administrator stated that the discharging hospital did not notify the facility of any wound upon placement. The administrator stated the facility staff reported to the administrator (date unknown) that R1 had an open wound on their ‘buttocks’ area. The administrator also stated that they “never saw the wound on R1.” However, it is the administrator’s responsibility to observe and monitor any wounds/pressure injuries for any changes. According to the administrator, the facility then called the discharging hospital and requested that they send a wound specialist. Additionally, the administrator stated that the Home Health nurse would call and provide an update on R1’s progress. Allegedly, however, the Home Health nurse did not disclose R1’s wound stages. Continue on LIC9099C.. However, it is the administrator’s responsibility to follow-up and ask those questions from the home health nurse. The administrator disclosed that the Home Health nurse advised via telephone, prior to the appointment on 9/28/21, that R1 was going to check themselves “into the ER to have the wound checked.” The LPA made numerous attempts to speak with the HH nurse to ask whether or not the nurse informed the facility staff of the wound stage; however, the nurse did not return the call. Staff interviews revealed that staff were able to move/reposition R1. Although the staff stated that R1 ‘was heavy,’ staff ‘always repositioned’ R1. Staff confirmed that R1 was a two-person assist, and repositioning would be conducted ‘often’ as they were ‘always in pain’; and, R1’s diapers had to be changed. Staff interviews further revealed that staff discovered the pressure injury on R1’s ‘bottom,’ and advised the Administrator (date unknown). Staff #1 (S1) stated that they discovered the ‘wound on his lower back,’ the first day R1 came to the facility (09/10/21). S1 also stated that there was an individual that accompanied R1 to the facility, who took photos, then ‘made calls.’ S1 stated that after that individual made the calls, nurses from home health began to visit R1 for wound care. The discharge documents did not note any wound on R1 upon discharge. The administrator stated she had no knowledge of R1 having a pressure injury upon admission to the facility; or, of the stage of the pressure injury. The facility staff failed to ensure that R1 was regularly observed for any changes; and, that appropriate assistance was provided when the observation revealed unmet needs. The staff also failed to document R1’s medical changes and notify the appropriate parties. R1’s Reappraisal was not updated to reflect the change of condition that R1’s pressure injury was worsening. Therefore, the licensee representative did not have a level of care meeting to discuss the change of condition with the resident, staff, and the home health agency. In addition, as a result, the licensee representative was retaining a resident with a prohibited health condition and failed to request an exception to retain that individual with a prohibited health condition. Based on the investigation, there is sufficient evidence to support the claim that due to neglect and lack of care and supervision, R1 sustained a pressure injury while in care. Therefore, this allegation is deemed Substantiated at this time. Continue on LIC9099C.. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. A copy of the report was issue, along with appeal rights. Regarding the allegation, ‘Facility staff are unable to meet resident's care needs,’ it is alleged that R1 was only at the facility for a month, and they could not handle R1, but accepted R1 from a hospital placement. It is also alleged the facility staff could not move or reposition R1 during the duration of stay. During the investigation, LPA Walker conducted interviews with the administrator, and facility staff. The LPA also attempted to contact R1 to obtain additional information. However, all contact numbers provided were no longer in service. Interviews with the administrator revealed that facility staff reposition residents that require repositioning ‘as needed.’ The Administrator stated that Resident #1 (R1) was repositioned approximately every hour. Interviews with the administrator also revealed that all facility staff are trained in repositioning. Interviews with facility staff revealed tthat staff were able to move/reposition R1. Although the staff stated that R1 ‘was heavy,’ staff ‘always repositioned’ R1. Staff confirmed that R1 was a two-person assist, and repositioning would be conducted ‘often’ as they were ‘always in pain’; and, R1’s diapers had to be changed. Based on conducted interviews and a record review, R1 was placed on Home Health to receive wound treatment upon staff reporting to the administrator that R1 had an open wound. Therefore, there is insufficient evidence to support the allegation ‘Facility staff are unable to meet resident's care needs.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. No deficiencies cited. Exit interview conducted and a copy of the report was emailed.