complaint·September 8, 2023

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident sustained multiple pressure injuries while in care. The details of the complaint alleged resident # 1 (R1) sustained multiple pressure injuries while in care at this facility. As reported on the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form. Specifically, the complaint focused on an incident that occurred on 12/14/21 when (R1) was hospitalized at Harbor UCLA Medical Center Hospital. Indicated on the (SOC-341) (R1) presented multiple wounds described in various stages from unstageable to wound healing in Stage 3. In medical records, a total of (15) wounds were identified. The Department reached out to the complainant for further comments but was not available. The Admissions Agreement indicated (R1) was admitted at Carson Senior Assisted Living (CSAL) on 04/19/21. (R1) was medically assessed according to (R1’s) Physician’s Report dated 04/19/21 as ambulatory in fair physical health status. (R1’s) capacity for self-care required assistance with activities of daily (ADL) however did not require continuous bed care and a history of skin breakdown. According to service records (R1) was admitted on 04/20/21 by St. Paul Home Health Services (SPHHS). Home health services included services 2 or 3 visits weekly by a licensed registered nurse who attended to (R1’s) medical health condition that included a wound care order. The medical records for (R1) presented between 04/19/21 to 12/14/21, (R1) transitioned between hospitals, skilled nursing homes, and Carson Senior Assisted Living (CSAL). As a result of these transitions, (R1’s) wound care orders remained consistent with St. Paul Home Health Services. Each time (R1) was readmitted back at (CSAL), (SPHHS) was reinstated. In accordance to a Medical Body Assessment and Body Documentation for (R1), wound assessment and care was conducted on 09/24/21, 10/14/21, 11/23/21, 11/24/21, 12/04/21 by (CSAL) (SPHHS) and Omni Wound Physicians (OWP). The West Coast Wound Company conducted an additional wound assessment and wound treatment plan on 12/02/21. No wounds were classified as stage 3 or stage 4 in any of the assessments. (Evaluation Report continues LIC 9099-C) Staff #1-#2 (S1 and S2) provided a written Declaration dated 04/14/22 indicating confirmation (R1) had continuous wound care under (SPHHS) and throughout transitions between hospitals, skilled nursing homes, and (CSAL). Interviews with (3) out (5) staff #3-#5 (S3-S5) on 04/18/22 all verified body assessments were conducted regularly and noted on charts for (SPHHS) and home health notified. (S3-S5) reported (R1) was able to reposition was not bedridden and was not neglected in care or supervision. On 04/04/22, the Department interviewed (9) out (166) residents #2-#10 (R2-R10) who had no pressure injuries and were complimentary of care staff. (R2-R10) reported care staff are caring, accountable, and responsive to residents in care. On 08/23/23, the Department interviewed resident #1 (R1) who is being cared for at Country Villa Belmont Heights Healthcare Center confirmed (R1) was on home health. When (R1) was a resident at (CSAL) that home health was assisting with (R1’s) wounds. (R1) reported the staff at (CSAL) were fair and they assisted when home health was not available. (R1) did not feel neglected and received assistance until (R1) required a higher level of care. (R1) stated that (R1) always had wounds and it was being addressed at (CSAL) to prevent further infections. (R1) stated (R1) was able to reposition (R1) in bed and was not considered as bedridden. (R1) does not hold the (CSAL) responsible for the wounds as (R1) was being assisted by home health services along with care staff at (CSAL). Based on information gathered, an inspection of the facility, observation, analysis of (R-1)'s service records medical records, and home health records, Declarations, and interviews conducted, the Department found no evidence to support NEGLECT OR LACK OF SUPERVISION: Resident sustained multiple pressure injuries while in care is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur as a result, the allegation is Unsubstantiated. An exit interview was conducted with Ginger Enriquez and a copy of the report was provided.