complaint·April 20, 2022

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident Developed a pressure injury while in care. It is alleged that resident developed pressure injuries while in facilities care due to staff neglect. IB Investigator Jose Santana conducted an investigation into the allegations which consisted of both records review and interviews. On 1/8/2020 Resident 1 (R1) was discharged from hospital on 1/8/2020 with notes stating resident had blanchable redness to coccyx and inner gluteal region. R1 entered facility on 1/8/2020. An initial assessment was conducted of their care needs and it was noted by facility staff on 1/9/2020 that resident did not require any skin care. On 1/10/2020 Doctors Choice home health visited R1 at facility to conduct an assessment and noted a stage 2 pressure injury on right buttock. Physician gave Doctors Choice home health a wound care order for treatment. Facility noted R1’s visit with Doctors Choice home health but did not have a report. It was stated during interview by S1 that facility would follow-up with Comfort choice home health, but a review or facility records does not show any documentation regarding follow-up. On 1/10/2022 R1 was admitted to St. John’s Health Center for another diagnosis and home health treatment stopped. R1 returned to facility on 1/16/2020 and home health services with Doctor’s Choice were not resumed. On 2/3/2020 a “blood blister” was found by facility staff on R1’s sacrum and Doctors Choice Home health was contacted. Doctors Choice home health resumed their treatment of R1 on 2/3/2020 and on 2/4/2020 it was noted that R1 had a stage 2 pressure injury on their mid-lower back/sacrum with a recommended wound treatment and a note to turn resident every two hours and not have them sit for too long. On 2/10/2020 the “blood blister” started to break open and Doctors Choice home health had not visited R1 since 2/4/2020. Another home health service was requested and after their assessment of an unstageable pressure injury on R1’s sacrum, primary care physician for R1 was contacted and recommended R1 be sent to hospital. R1 entered hospital on 2/12/2020 and was diagnosed with three pressure injuries, redness to heals, one pressure injury on right hip and unstageable pressure injury on right sacrum. Based on observations, interviews, and record review(s), the preponderance of evidence standard has been met. On 2/12/2020 R1 was admitted to St. Johns Health Center and present during admission were three pressure injuries: redness to heels, one pressure injury on right hip and unstageable pressure injury on right sacrum. Records and interviews indicate that there was a break in home health coverage from 1/16/2020 when R1 returned from hospital to 2/3/2020 when “blood blister” was found by facility staff. Therefore, the allegation, is found to be SUBSTANTIATED . California Code of Regulations, Title 22 are being cited on the attached LIC9099-D. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1) Exit interview conducted, appeal rights were discussed, and a copy of this report and appeal rights was provided to Business Director Amy Burgreen.