complaint·April 30, 2021

retrieve wound care services for R1 after R1 developed multiple pressure injuries. Based on the records that were reviewed, the interviews that were conducted, and the information obtained, although the facility called 9-1-1 on 04/08/20 to address R1’s health condition, the Administrator at the time of the incident (not Lesly Figueroa) failed to call non-emergency after the fire department declined to transport R1 for having insufficient symptoms. Based on the information, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated Citations issued on the LIC9099-D and appeal rights given. LPA also advised the administrator that a possible ECP may be warranted. A telephonic exit interview was conducted with Administrator Lesly Figueroa, and an electronic copy was provided via email for signature. transport R1 for having insufficient symptoms. Additionally, the facility kept R1 in the same room as another resident exhibiting symptoms that Long Beach Health Dept. identified as potential COVID-19 symptoms, for which isolation was required. This other resident continued sharing a room with R1 until 4/11/2020, when the resident was transported to the hospital and was found to have pneumonia (but no COVID-19). The facility should have presumed the roommate was COVID-19 positive; its failure to isolate residents was not aligned with CCLD directives. The facility retained the resident at the facility for IV hydration treatment under care of CareMore Health. Even if an argument can be made that the facility followed appropriate COVID-19 protocol based on the Long Beach Health Dept. directives, the facility took no measures to address the many pressure injuries on R1’s body, and it retained him despite an unstageable pressure injury on his right elbow, a prohibited condition. Further, the facility not only took inadequate measures to address R1’s increased fall risk and the injuries he sustained during an unwitnessed fall that resulted in bruising to the right side of his chest, but it actually barred home health physical therapy from assessing R1, stating that this service was “non-essential” during the facility lockdown. Lastly, and perhaps most significant, the facility failed to seek adequate medical attention for R1’s caloric deficiency, weakness, and increased confusion, all of which were signs of a change of condition, which the assistant administrator and a facility License Vocational Nurse believed was sufficient reason to seek hospital evaluation. The facility was not responsive to the POA, CareMore, or the home health company during this time, creating slight delays in, and in the case of physical therapy, the barring of, the resident’s treatment. Rather than allow a physical therapist to assess R1 and prevent additional falls, facility administrator Russell Amparano informed staff members to advise R1, who was in a confused state, not to attempt to get out of bed unassisted. R1 ultimately developed an unstageable pressure injury on his right elbow, along with several stage I pressure injuries throughout the right side of his body but received no wound care. The allegation that the facility failed to seek timely medical attention for R1 is Substantiated”. The investigation revealed the following for allegation: (Facility failed to meet residents medicals needs which resulted in resident death) Based on interviews conducted by Investigator Jose Santana and LPA Williams, the facility did fail to keep R1 separate from another resident who should have been isolated due to having Covid-19 symptoms. Additionally, the facility did not react appropriately to the change of condition for R1. The facility also failed to