complaint·April 1, 2022

(Continued pg 2) physical health status: “history of skin condition or breakdown- YES “buttocks.” Ambulatory status: non-ambulatory. On 5/05/2021 LPA Brown interviewed Administrator, Miki Lamm; she indicated that R1 was on home health with Torrance Memorial Home Health, the request was made on 11/20/19. First pressure injury was observed on 11/21/19 which was located on residents left heel. On 11/27/19 resident was admitted to Torrance Memorial Hospital due to shortness of breath. LPA Cardenas conducted resident file review and there is no available evidence that Home Health was treating R1’s pressure injuries. There isn’t documentation of a Home Health care plan with a start date for pressure injuries. LPA Cardenas interviewed Lamm, and according to the administrator the resident’s Physician “did not want to place the resident on home health .” Per Medical records from Torrance Memorial Medical Center Hospital Progress Note from 10/21/19; Reason for visit: RESPIRATORY INFECTIONS & INFLAMATION W MCC & MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS. Diagnosis Pneumonia. Pressure Ulcer present on admission, Other: BUTTOCK/SACRUM/ COCCYX, Stage I; Wound Care Consultation 10/21/19; discharged 10/22/19. Resident given patient education materials, prescriptions, and follow up with your Physician within two weeks of discharge. Facility Staff#7 (S7) stated to TMMC that, Patient was supposed to be on service with Dynamic Home Health upon discharge from Torrance Memorial Medical Center on 10/22/19. However, Dynamic Home Health only came out once and then patient was discharged due to insurance problems. Since 10/22/19, S7 states that no Home Health has been coming out to manage wounds. Patient is being followed by Primary Care Provider (PCP). On 11/28/19 Resident was admitting into the hospital diagnosis is Respiratory Infections & Inflammation. Also present were Pressure Ulcer of Left heel - Stage 3; Pressure Ulcer of Right heel – Unspecified Stage; Pressure Ulcer of Sacral Region – Stage 2. (Continued pg 3) Per LPA Cardenas record review of Torrance Memorial Case management notes dated 11/29/19: PT “presented with respiratory failure, patient “(PT) also with multiple wounds on his heels/ buttocks. “Per Torrance Memorial – social services record dated 11/29/19 patient (PT) was brought in with pneumonia… “RN noticed wounds on heel of foot which patient did not have at last hospital admission (10/19/19 )…” called assisted living facility and spoke with LVN staff#6 (S6) who stated that they have tried to obtain home health services however, encountered some insurance problems and also the home health agency "couldn't take because they were overbooked." Per Facility Licensed Nurse Notes dated 11/20/19; “Currently finding a new home health facility for resident to be seen. Called Miracle & Oceanside both require MD referral DRCS (delivery receipt confirmation system) faxed resident’s PCP for referral. Based on LPA’s observations, interviews, and record review(s), the preponderance of evidence standard has been met. On 11/28/19 R1 was admitted to Torrance Memorial Medical Center, present during admission: Pressure Ulcer of Left heel- Stage 3; Pressure Ulcer of Right heel – Unspecified Stage; Pressure Ulcer of Sacral Region – Stage 2. Staff indicated that Home Health was not assigned due to insurance, and agency being overbooked. Therefore, the allegation, is found to be SUBSTANTIATED . California Code of Regulations, Title 22 are being cited on the attached LIC9099-D. 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 of impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” 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 was provided to Director of Resident Care Services, Nina Khatchatrian .