complaint·June 18, 2021

R#1 was later transferred to PIH Whittier Hospital on 10/15/19. During R#1’s hospital stay at PIH Downey Hospital, it was noted that there were numerous unstageable pressure injuries to R#1’s coccyx, toes and heels, however, the photos and staging were dated 10/15/19. The pressure injuries were noted as being stage 2 and/or unstageable and there was no clear indication of the stages of each pressure injury or clarification on whether the staging was the same upon admission to the hospital on 10/07/19. Additional notes indicate pressure injuries to various parts of R#1’s body were at stage I or stage II except for one pressure injury which was unstageable. It was also indicated in R#1 hospital records that hospital staff noted pressure injuries can develop fast, within hours. R#1’s family member reported that nobody observed R#1 having any pressure injuries while residing at the facility. Based on interviews with facility staff, residents and review of R#1 facility records and R#1 medical records dated 10/07/19, R#1’s was admitted to the facility on 09/24/19, a skin assessment was conducted and staff noted R#1 did not have any pressure injury. On 09/29/19 facility notes indicate a small superficial skin tear on R#1’s left buttock due to scratching and treatment was applied. On 09/30/19, small skin tear to the left buttock was noted and treatment was applied. On 10/04/19, staff conducted a body check on R#1 with R#1’s family member present and it was noted that aside from R#1’s buttock area, there was no other skin tears/redness and no open wounds observed. On 10/05/19, facility noted that R#1’s skin was intact, redness was present and no skin breakdown. On 10/07/19, staff checked R#1’s buttock area and noted that R#1 still had a superficial skin tear and the area was cleaned. Interviews with facility Staff #1 and #2 both indicated that Staff #1 and #2 did not notice R#1 to have any pressure injury, only a small superficial skin tear. Based upon the investigation, there is no evidence to support that R#1 developed multiple pressure injuries while in the care of the facility and there is no clear indication as to when R#1’s developed the pressure injuries. It is possible that R#1 pressure injuries may have developed after R#1 was hospitalized on 10/07/19. Based on the department's interviews and record review, investigation revealed: 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. Exit interview conducted with Cynthia Flores and a copy of this report was provided.