complaint·July 27, 2021

On or about 01/20/2021, R1 began to develop small ulcers on coccyx due to lack of mobility. A Home Health Licensed Vocational Nurse (LVN) was assigned to continue providing services and also began treating the pressure ulcers. Administrator stated that rotating R1 side to side, R1 began developing skin tears on both sides of the hips. On 01/19/2021, Administrator stated she requested from Home Health a wound specialist to see R1. On 01/26/2021 Home Health LVN told Administrator she believed R1’s wound was improving, and no wound specialist was recommended. Home Health LVN requested an air mattress for R1 and continued treating the ulcers and reporting to the physician. On or about 01/29/2021, R1 developed additional small ulcers across the lower extremities across left hip to right hip and the ulcer on coccyx had developed into a stage two. Home Health LVN along with facility caregivers attempted to treat the ulcers by continuing to rotate R1. On 02/04/2021, Home Health LVN requested that R1 be evaluated by Green Meadows Home Health Nurse Practitioner (NP) and another Home Health LVN. It was determined by the NP that R1’s pressure ulcer on coccyx had worsened but was going to wait for a wound specialist on 02/05/2021 to evaluate and treat the ulcers. On 02/06/2021, facility Administrator sent R1 to the hospital because no wound specialist had come out and Home Health LVN said R1’s ulcer developed to a stage four and had worsened. The facility requested numerous times to have R1 be seen by a wound specialist or a physician. They documented daily R1’s status and services they provided. The facility did not call 911 when staff observed R1’s change in condition and their inability to lift or move R1. In addition, Administrator stated facility was short staffed due to COVID-19 and aware R1 required two-person transfer. R1’s assessment was done via phone. Facility was aware of R1’s health condition (heart failure, hypertension, sensitive due to skin cancer, history of bed sores, no mobility due to knee surgery, cellulitis of right and left limbs, muscle weakness) per Appraisal/Needs and Services Plan dated 01/01/2021. Green Meadows Home Care prolonged the request of a wound specialist which never came and requested an air mattress which never came. The facility made the decision to send out R1 to UCI Health Care Hospital on 02/06/2021 because his ulcers worsened to a stage four rather than continue home care services. The facility is responsible overall for the condition and well being of the resident and should have provided timely medical attention sooner regardless of R1 receiving Home Care services. Both facility and Green Meadows Home Care failed to provide timely medical attention subjecting R1 to immediate decline in health and unnecessary pain and suffering. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division 6), is being cited on the attached LIC 9099-D. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49 An exit interview was conducted with Administrator and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) and LIC811.