complaint·September 28, 2023

The investigation revealed of the following: Allegation#1 “Facility retained resident with a prohibited health condition.” R1 was admitted to the facility on 12/28/20 but due to R1’s declining health and began to receive home health services on 1/1/2021. R1 began receiving home health services due to R1’s advanced age, decline in mental health, increased weakness and decline in functional status and incontinence. Per review of medical records obtained and the following was determined: On 01/04/21, R1 developed pressure ulcers on both buttocks. On 1/7/21, it was determined that the pressure ulcers on the left and right buttocks were determined to be stage 2. By 02/01/21, R1 had a total of 4 pressure ulcers determined to be stage 3. It was reported the pressure ulcers worsened over time. Although home health contacted the wound doctor to provide evaluation and treatment for R1, the facility continued to retain the resident with a prohibited health condition and failed to submit an exception request to the Licensing Department. Allegation#2 “Resident received a pressure injury while in care” R1 was admitted to the facility on 12/28/20 and R1’s family doctor ordered a home health service for R1 due to R1 was bedridden, weakness, and limited mobility. R1 was also identified as high-risk requiring emergency care services and hospitalization due to advanced age, decline in health and incontinence with a high risk of breakdown. It is alleged that when R1 was admitted to the facility on 12/28/20, R1 had a red mark on their buttocks area. Facility staff was aware of this. On 1/7/21, R1 was reported to have two pressure ulcers which had developed on left and right buttocks which were determined to be stage two. On 1/28/21, its documented that R1 developed three pressure ulcers. By 2/1/21, R1 had a total of 4 pressure ulcers with two stage 2, one deep tissue injury and one stage 3 pressure ulcers. Additionally, the facility also did not update, develop, and implement a plan of care when home health identified R1 was at risk of developing pressure ulcers. Allegation #3 “Staff did not notify authorized representative of residents change in condition” R1 was admitted to the facility on 12/28/20 and family took R1 out from the facility on 3/29/21. It was reported that prior to R1 admitted into the facility, R1 did not wear diapers and was not in wheelchair. It is alleged that, R1's family members were not allowed to be visited R1 in person due to COVID and visitors were only able to communicate with the facility through phone calls. According to R1’s family member, the administrator never provided any updates regarding R1’s change in health condition including that R1 had developed pressure ulcers while residing at the facility. R1’s family members stated that they attempted to go to the facility to visit R1 however due to COVID, she was not allowed to see R1 at the facility. (See LIC 9099C for continuation) R1’s family member also tried calling the administrator many times for follow up on R1’s health condition, but the administrator never communicated any updates regarding R1’s pressure ulcers. R1’s family member indicated that she was unaware of R1’s pressure ulcers until R1's family member took R1 out from the facility on 3/29/21 and a hole was observed on R1’s sacrum. At that time, R1’s pressure ulcers were staged by a doctor to be stage 4. No one in the facility notified R1’s family that R1 had developed these wounds. Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(e) & (f) and may be assessed at a later date. Exit interview was conducted and a copy of this report was provided, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Allegation “Staff did not seek timely medical care for the resident” R1 was admitted to the facility on 12/28/20, and R1’s initial Needs and Service Plan indicated that R1 had smelly urine. Facility did consult with R1’s primary care physician who ordered the home health services for R1. Home health ordered physical therapy for evaluation of physician status and rehabilitation. On 2/1/21, R1 developed total of 4 pressure ulcers and reported the pressure ulcers had worsened. Home health ordered the wound doctor for R1 to provide wound evaluation and treatment as needed. Before R1’s family took R1 back home on 3/29/21, R1 was under the care of a wound doctor. Wound doctor follow up on R1’s pressure injuries every 7 days until the last visit on 3/24/21. Based on record review and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED, Exit interview held and a copy of the report was provided.