Complaint·October 7, 2021

on the left buttocks increasing in size, on 01/12/2020 Physicians order indicate that R1 had unstageable pressure injuries on the left and right buttocks, on 01/20/2020 the wound on R1’s left and right buttock combined as a sacral wound and was unstageable. Home Health Records indicate that R1 had Unstageable and stage III pressure injuries. Hospital records indicate that, on 02/19/2020 R1 was sent to the hospital and was diagnosed with stage III and unstageable pressure injuries then was discharge to the facility and on 02/28/2020 R1 was sent back to the hospital where R1 was admitted. On 05/26/2020 IB interviewed the administrator Rosendo Carlo Miranda who stated that: towards the end of February 2020 R1’s home health nurse advised that “the wound was getting worse and R1 needed a higher level of care”. The administrator also stated that they recommended to R1’s family that “R1 needs to be transferred to a skilled nursing facility”. The administrator stated that “The wound may have been a stage III the last week of R1’s family was arranging the transfer." And after a week and a half the administrator decided to call an ambulance to transfer R1 to the hospital. IB observed that the administrator’s statements seem to coordinate with R1’s hospitalization on 02/19/2020 and 02/28/2020. Regarding the allegation: Resident developed a prohibited health condition while in care. Based on IB’s observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Civil Penalties were assessed on a similar allegation during investigation of another complaint with control number 11-AS-20200309132542. 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, plans of corrections were discussed. A copy of this report and appeals rights were provided. On 03/10/2020 staff S1 stated that “R1 had a sore at their bottom and wore diapers and R1 would go pee in their diapers, so their wound area was constantly wet from pee.”, and stated “We changed R1’s diapers when needed and rotated them every 2 hours.” On 09/25/2020 Witness W4 stated that “On 01/21/2020 R1’s bed cover was wet with what smelled, like urine I would go different times after that, to try and see but I did not observe R1 being wet". Regarding the allegation: Staff left resident in soiled diaper. 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, therefore the allegation is unsubstantiated. No deficiencies cited. An exit interview conducted, a copy of this report was provided.