complaint·April 8, 2022

Regarding Allegation #1 : this investigation revealed that Resident #1 (Referred to as R1) was a resident at the facility and was receiving home health care services. R1 was admitted to the hospital on 02/25/21 for multiple pressure injuries: Left lateral knee (Stage 2); Left foot (purple); Left hip (unstageable); Right heel (purple); Right lateral malious (purple); Right lateral foot (purple-deep pressure injury); Right medial foot (marron); Right hip (unstageable); Left lateral calf (stage 2). On 02/22/21 R1’s diagnosis elevated to a right hip pressure ulcer – Stage 4 (measured: 5x5.5 x 0.8 cm) with moderate purulent drainage with foul smell; left hip (measured: 7 x 6.5 x 0 cm) covered with yellow and gray slough (100% with moderate purulent drainage and foul smell). Right hip pressure ulcer Stage 4 (measured: 5cm x 5.5cm x 0.8cm) with 60% red wound bed and 40% yellow slough. Left hip pressure ulcer (unstageable) – measured: 7cm x 6.5cm x 0cm covered with 100% yellowish slough (now, almost double in size) with foul smell. Facility staff were assisted weekly by Home Health Agency (HHA) skilled nurse who worked together to provide care for R1. In addition, weekly training was being provided to facility staff as to the needs of R1. Facility staff applied first aid and would reposition R1 every 2 hours to prevent further injury. The care plan explains the care provided to R1 by the HHA skilled nurse and facility staff which was consistent with documentation in R1’s care plan instructions. Facility staff reported that R1 would regularly remove its diaper and scratch its wounds and was unwilling to allow the HHA skilled nurse to perform wound care. Based on the evidence gathered, interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident sustained multiple pressure injuries while in care is found to be SUBSTANTIATED. Regarding Allegation #2 : this investigation revealed that Resident #1 (Referred to as R1) was receiving care by a Home Health Agency (HHA) while at the facility. On 02/22/21 R1’s diagnosis elevated to a right hip pressure ulcer – Stage 4 (measured: 5x5.5 x 0.8 cm) with moderate purulent drainage with foul smell; left hip (measured: 7 x 6.5 x 0 cm) covered with yellow and gray slough (100% with moderate purulent drainage and foul smell). HHA skilled nurse documented R1’s wounds were getting worse and that R1 continued to deteriorate. On 02/24/21, R1’s wound culture obtained, both hips and documented: Left hip – 100% stricken foul, pungent odor wound. Resident has pressure ulcers – Stage 2. Deep tissue injury at right hip and inner knee with dry scab. HHA skilled nurse recommended hospitalization for wound debridement. Right hip pressure ulcer Stage 4 (measured: 5cm x 5.5cm x 0.8cm) with 60% red wound bed and 40% yellow slough. Left hip pressure ulcer (unstageable) – measured: 7cm x 6.5cm x 0cm covered with 100% yellowish slough (now, almost double in size) with foul smell. HHA skilled nurse documented Resident was referred to higher level of care. Resident needs total care. On 02/25/21, R1 was hospitalized and diagnosed with multiple pressure injuries: Left lateral knee (Stage 2); Left foot (purple); Left hip (unstageable); Right heel (purple); Right lateral malious (purple); Right lateral foot (purple-deep pressure injury); Right medial foot (marron); Right hip (Stage 4); Left lateral calf (Stage 2). Based on medical information provided by the Home Health Agency’s skilled nurses (between 01/03/21 to 02/25/21) to Administrator and facility staff, R1 was diagnosed with unstageable and Stage 4 dermal ulcers on 02/22/21. R1’s dermal ulcers required a higher level of care than what facility staff were able to do or provide. Administrator Medina was required to immediately transfer R1 at the point, but failed to do so. Based on the evidence gathered, interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of LEVEL OF CARE: Facility retained a resident with a prohibited health condition is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency observed and citation issued (ref. LIC 9099D). Civil penalty assessed. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted and a copy of the Complaint Report and Appeal Rights were provided to Administrator ((Lorenzona “Elvie” Medina).