complaint·March 17, 2023

Allegation: Staff neglect resulting in resident developing a pressure injury while in care. The finding of this allegation has been determined by evidence in the investigation report of Investigator Philippe Miles. The investigation report includes: Resident (R1's) hospital medical records, Palliative Care records, Wound Physician records, Physician Report, Plan of Care, resident appraisals, and photographs. Resident (R1) was admitted to the facility on 9/29/2020. Per Preplacement Appraisal completed on 10/02/2020, resident was alert and oriented, non-ambulatory, used a wheelchair and required help in all activities of daily living (ADLs). Pa ll iative care by Corinthian Hospice was initiated on 10/05/2020. The assessment revealed that R1 had Stage 1 on both groin areas, left and right stomach folds, and Stage 2 sacral area; nurse visits were scheduled 1-2x/week. Facility staff admitted they provided wound care prior to Hospice/Palliative Care start. When the resident was admitted to the facility there were open wounds on thighs, and rashes under belly that emitted a foul smell. On 10/15/2020, Palliative Care nurse notes state a Stage 3 to sacral coccyx area was observed. Facility staff were educated by nurse on repositioning, skin integrity, ad preventing skin breakdown. On 11/23/2020, resident (R1) was transferred to Methodist Hospital of Southern California and was diagnosed with septic sho ck, acute kidney injury, and aspiration pneumonia. On 11/25/2020, the resident was transferred to Kaiser Permanente Hospital with the following active diagnoses: septic shock, pressure ulcer of coccyx, Sacral Deep Tissue Pressure Injury (DTPI) previously a Stage 3, with open linear sore; Measurements 3 x 0.5 cm, new Right ankle DTPI; Measurements: 0.5 x 0.5 cm, Stage 4 Midback open wound; Measurements: 3 x 3 x 2.5 cm, and aspiration pneumonia. On 11/27/2020, the resident was discharged back to the facility with a Foley catheter. On 11/30/2020, R1 was readmitted to Corinthian Hospice for Palliative Care. On 1/7/2021, resident (R1) developed a new stage III pressure wound on the coccygeal area. On 10/23/2021, R1 was transferred to Country Villa Health Care Center Long Beach per MD order due to unresolved skin rashes to bilateral upper thighs. On 12/14/2021, R1 was discharged from California Mission Inn. After hospitalization the resident was transferred to a different board and care facility. The resident died on 5/13/2022. There is sufficient evidence to corroborate the allegation. The resident developed pressure injuries while under the care of the facility, and was admitted to the hospital with deep Stage 4 pressure wounds. Per evidence review presented in the Investigation Case Report, medical records, and interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22 are being cited on the attached LIC9099D. **The licensee was informed that a civil penalty might be assessed based on Health and Safety Code. Exit interview was conducted with Wellness Director Ruby Magao. A copy of the report and appeal rights were issued.