complaint·April 29, 2021

Hospital medical staff observed that R1 had a stage II PI in the Sacrum area. The hospital referred R1 to a Home Health agency for wound care. Home Health agency staff went to the facility and provided wound care to R1. Home Health advised that during the course of wound care treatment, the wound started to develop an odor, so Home Health requested for staff to move and/or reposition R1. There was also documentation that indicated R1 was in so much pain they would cry so Home Health recommended for R1's dressing be changed two or three times daily as they observed R1's wound dressing to be saturated with urine and bowel, and also for staff to reposition R1 every 2 hours to prevent the PI from getting worse. Home Health also recommended for staff to request pain medication for R1 to assist with the pain. On 02/14/20 R1 attended their doctors appointment for evaluation and wound care. The treating Physician discovered that R1's PI was at a stage III which had to be packed, as it has grown in size and gotten deeper. On 02/18/20 R1's PI was unstageable. LPA Wesley conducted interviewed the Administrator, staff, R1's family and other parties, and it was communicated that there were no concerns that R1 was neglected, but a dissatisfaction that the facility staff were not providing adequate wound care for R1. LPA Wesley interviewed the Administrator Lilian Ikpeamaeze who said there are 3 residents who are on Hospice and 1 resident who receives assistance from a home health agency and she advised that she and the staff provides the resident's with proper assistance and follow the instructions from the Hospice and Home Health Providers. LPA Wesley interviewed staff #1 and staff #2 who also said they provided proper assistance to the residents in care and also provides assistance with keeping the resident's wound dressing clean and dry . Based on LPAs observations and interviews which were conducted 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. Immediate Civil Penalties will be issued today, in the amount of $500.00 due to resident sustaining an unstageable Pressure Injury while under the facility care. A telephonic exit interview was conducted with Administrator Lilian Ikpeamaeze, and a hard copy was provided via email to obtain signature. **This is a corrected copy of the LIC 9099/LIC 9099C/LIC 9099D that was provided to Administrator Lilian Ikpeamaeze on 04/29/21 to obtain signatures.**