complaint·November 2, 2023

INVESTIGATIONS REVEALED THE FOLLOWING: Allegation: Resident sustained a pressure injury while in care It is alleged resident sustained a pressure injury while in care. Based on records review, Admission Agreement indicates R1 was admitted to the facility on 5/14/2020. Physician’s Report dated 5/11/2020 and the facility’s Progress Notes dated 5/14/20 indicate R1 has a history of deep tissue pressure injury on the right lateral heel, stage not noted. R1 is non-ambulatory. R1’s Medication Administration Record (MAR) shows facility staff administered Venelax topical ointment from 5/14/2020 through 7/6/2020, 2x day on R1’s right heel for suspected deep tissue pressure injury. During the Torrance Memorial Home Health Nurse’s visit on 5/17/2020, home health nurse instructed caregivers on resident’s Stage 1 Pressure Ulcer to Right Heel to keep off pressure, leave open to air and other measures to prevent skin breakdown. The facility’s progress notes dated 5/17/2020 indicates home health nurse verbalizes nurses will continue to visit once a week and the facility staff/caregivers will continue to assist R1 with repositioning four times per shift and floating right heel on pillow. On 5/22/2020, the facility’s progress notes indicate R1 had a quarter sized open area with surrounding redness on coccyx, care team to continue to apply barrier cream and reposition resident and home health nurse is to visit on 5/23/2020. On 5/31/2020, the facility’s progress notes and the home health notes revealed R1 had developed an open bed sore on the coccyx area. According to the department’s records review, there were no records that R1 received wound care for coccyx from Home Health and no records were found that facility staff repositioned R1 between 5/23/2020 and 5/30/2020. In addition, there was no evidence that the facility made attempts to follow-up on the request for home health services or medical assessment for R1’s coccyx during this period. However, home health continued in providing wound care to RI's right heel. On 6/2/2020, a new home health service for R1's coccyx commenced and it was revealed that R1 developed an unstageable pressure injury on coccyx. On 6/28/2020, Home health notes show R1’s pressure injury in coccyx was at Stage 3 and it progressed to Stage 4 on 7/12/2020. Based on interviews conducted with four out of eight staff (S1, S2, S4 & S8), R1 developed a pressure injury while in care. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met: Due to neglect/lack of supervision, Resident #1 developed an unstageable pressure injury on coccyx, therefore the above allegation “Resident sustained a pressure injury while in care” is found to be SUBSTANTIATED. REPORT CONTINUED IN LIC 9099-C Pursuant to Title 22 Division 6 of the California Code of Regulations, following deficiency was cited (refer to LIC 9099-D). 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 Eric Mensah.