Inspector’s narrative
What the inspector wrote
On 11/18/22, a subsequent tele-visit was conducted by Investigator Brian Slatic, during the visit, Investigator Slatic interviewed staff from staff#1 (S1) to staff #4 (S4) which included Administrator/Licensee; interviewed resident’s representative (RR) from RP1 to RP3; interviewed local law enforcement (P1); obtained resident records from hospital and obtained records from local law enforcement. IB reviewed resident#1 (R1)’s facility file and any related documentation.
Regarding allegation: resident sustained a stage 4 pressure injury while in care. It was alleged that due to staff neglect, a resident had a stage 4 pressure injury on resident’s Sacro Coccyx area while in care. During the investigation, the department interviewed staff from S1 to S4, responsible party (RP) from RP1 to RP3, and Whittier Police Department. The department reviewed R1’s facility file and reviewed R1’s hospital records. Per interviews with staff, on 07/31/22, staff #1 observed R1’s buttock area was a little raw. On 08/02/22, staff #1 observed R1s sore opened up and R1’s responsible party was notified. On 08/04/22, staff #1 indicated R1’s coccyx area had skin peeling off and outer area was reddened and staff notified R1’s responsible party. On 08/05/22, staff reported R1’s pressure sore was equivalent to the size of a quarter coin. On the same day, R1 developed a severe fever of 100-degree Fahrenheit and staff notified R1’s responsible party. R1 was sent to hospital for observation and treatment. Upon admission to the hospital, R1 was diagnosed with a Stage 4 pressure ulcer. R1’s sore was as extremely large and required surgery. On 08/07/22, R1 had surgery at the hospital. Per R1s file review, on 7/31/22, R1 had redness on buttocks, however, the facility did not address or document R1’s pressure injuries on R1’s care plan and R1 had not been admitted to hospice or R1 had not undergone a hospice evaluation. The facility had contacted a hospice nurse to schedule an evaluation of R1, however, R1 was not evaluated by Hospice until around 08/06/22 or 08/07/22. Thus, R1 developed a prohibited health condition, a stage IV pressure injury to the Sacro-Coccyx area, which was unstageable. Therefore, staff retained R1 with a prohibited health condition and failed to ensure R1 pressure wound was treated by a licensed medical professional.
Regarding allegation: resident was diagnosed with sepsis and E-Coli. It was alleged that R1 had sepsis and E-Coli while in care. The department reviewed R1’s hospital records. On 08/05/22, R1 was sent to for evaluation at a local hospital due to R1 being hot to the touch and having a fever. Upon admission to the hospital, R1’s medical records and lab results indicated R1 had severe sepsis and E coli. The facility staff were aware of R1’s mental and health decline over the past four days prior to the hospital admission.
(-continued in LIC 9099C-)
However, the staff did not seek and/or provide R1 with immediate medical assistance, despite R1 changes of condition. Therefore, staff failed to obtain medical treatment for R1 who upon admission to the hospital was diagnosed with Sepsis and E Coli.
Regarding allegation: staff did not seek medical attention to resident in a timely manner. It was alleged that staff did not provide a resident with medical attention timely. The department interviewed staff. Per staff interviews, on 07/31/22, the facility staff were aware of R1 had was raw on R1’s buttock. On 08/02/22, the staff observed R1’s change of condition. Per staff, R1’s pressure wound/sore on Sacro-Coccyx was observed to be raw and the R1’s pressure wound had opened up. Staff notified R1’s family/authorized representative about the R1’s opened pressure wound/sore. R1 was scheduled to have a hospice evaluation on 08/06/22. However, on 08/05/22, R1 had a severe fever and R1’s wound on the Sacro Coccyx opened up. Staff reported R1’s sore to be equivalent to the size of a quarter coin. As mentioned above, R1 was hot to the touch and the facility staff noted R1’s fever. R1 was physically and mentally declining over the past four days. As a result, on 08/02/22, R1’s had a change of condition, on 08/05/22, R1 was sent to hospital for evaluation and treatment. Upon admission to the hospital, R1’s medical records indicated R1 had sepsis, E-Coli, and stage 4 pressure injury. Per R1’s record review, the R1’s pressure injury was around the size of a basketball and down to the bone. Therefore, staff were aware of R1’s changes of condition on 08/02/22, however, staff neglected to seek timely medical attention for R1 until 08/05/22, upon which R1 required surgery for R1’s pressure wound.
Based on interviews conducted and documents reviewed, 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.
An immediate $500 civil penalty is being issued during today's visit due to the neglect/lack of care and supervision resulting in resident sustaining a stage IV pressure injuries, sepsis, and E-coli.
The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).
Exit interview conducted with Staff#4. Appeal Rights was discussed and a copy was given during visit.
