complaint·July 22, 2024

The investigation revealed the following: Regarding allegations: Staff neglect let to resident sustaining wounds, Staff did not notify authorized representative of resident’s wound which resulted in hospitalization, and Staff did not provide timely medical care for resident. It is alleged R1’s representative noticed a wound on R1’s foot, staff facility was notified by R1’s representative of wound who agreed to have in-house physician follow up, wounds have been present for several months, and R1’s representative did not receive any update regarding foot wound. On 6/13/23, R1’s family member visited R1 at the facility. Family member assisted R1 with a shower and noticed R1 had a wound. On 6/13/23, R1’s representative was notified by family member of wounds and representative then notified staff #2 (S2) via email of the wound on R1’s left heel. S2 replied that they will assist R1 with medical attention. On 6/19/23, R1 was send out to the hospital due to complaints of pain. On 6/22/23, R1 was discharge from the hospital to a skill nursing facility (SNF) for care. On 7/12/23, R1 was discharge from SNF and returned to the facility. On 7/14/23, R1 initiated home health care. On 7/20/23, wound care agency evaluated R1 and noted R1’s wound still open which measured 3.5cm by 3.5cm. On 7/22/23, R1 was transferred from the facility to a SNF for care. Interviews conducted with facility staff revealed, that facility staff were aware that R1 had developed left foot wound, and three staff stated the wound in R1’s left heel was present for several weeks. Per Incident report dated: 6/19/23 staff contacted wound specialist regarding R1’s left heel wound, who recommended triple antibiotic ointment and recommended to send R1 to the hospital. Medical records reviewed, revealed R1 was seen at the hospital on 6/19/23 for a wound on the left heel. The wound was described as a “left heel wound with black color”. Hospital also noted on the history that paramedics stated resident was brought to the hospital for “evaluation of a wound on the left foot which has progressively worsen and the wound has been present for about a week, increasingly red and swollen.” On 7/26/23, Wound Care services noted a wound on “Left, Lateral Heel is a Wagner Grade 1 Diabetic Ulcer and has received a status of Not Healed.” The wound’s measurements were 3.5cm length x 3.5cm width x 0.1cm depth. Based on the interviews conducted and documents reviewed facility staff were aware of the wounds before the hospitalization on 6/19/23, R1’s representative notified S2 on 6/13/23 of the wound, there is documentation that a wound specialist recommended R1 to go out to the hospital, R1 went out to the hospital on 6/19/23, six days after the wound was reported to staff, and family representatives were not communicated regarding the wounds either prior to 6/19/23 or after. (CONTINUED ON LIC 9099C) Based on LPA's interviews and conducted of record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to Resident #1 sustaining a wound to the left heel, worsening due to health conditions, and facility staff not seeking medical attention in a timely manner while in care. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect. Exit interview was conducted with Cynthia Flores and a copy of this report, LIC 9099D, and appeal rights were provided.