Incident investigation·December 12, 2023

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit in response to an incident report sent to licensing on 11/20/23. LPA arrived unannounced and met with Staff, Cherry Serame. The purpose of the visit was explained. The incident report indicated that Resident #1 (R1) developed a wound on 11/20/23 that was unstageable at the time. During the visit today, LPA reviewed medical notes and interviewed staff. Staff interviewed stated that they first noticed redness on the right buttock of R1 on 11/10/23. They immediately informed the administrator who contacted the home health agency. On 11/13/23, a home health nurse conducted the initial visit to evaluate and treat the wound. Based on the Omni Home Health progress notes dated 11/24/23, the wound on the right hip was evaluated as a stage 3. The nurse had recommended to turn R1 every 2 hours and to keep the skin clean and dry. Additional progress notes dated 12/1/23 and 12/5/23 indicated the pressure ulcer was at stage 4. R1 was transferred to a Skilled Nursing Facility as initiated by the Regional Center personnel on 12/6/23. Staff interviewed stated R1 was not on hospice and the wound appeared to be healing while in care. They also stated R1 was turned every 2 hours. However, at night, a staff would check on R1 once, between 8pm - 6am, and turn R1 at that time. Based on the information gathered, the facility retained resident with a stage 3 or 4 wound which is considered a prohibited health condition. Therefore, a deficiency is being cited on the LIC809D. An exit interview was held and a copy of this report along with appeal rights were given to the administrator.