complaint·January 24, 2023

Resident Appraisals, Preplacement Appraisal Information forms, and Admission Agreements. R2 was sent out to the hospital on September 22, 2022 due to difficulty breathing. At Los Alamitos Medical Center R2 was diagnosed with Acute Cystitis, Acute Hyperglycemia, Severe Anemia, Severe Sepsis among other conditions. While at Los Alamitos Medical Center additional consultation by a Social Worker was requested due to the presence of a pressure injury on R2’s sacral region as well as redness on one of R2’s heels. Four of four individuals interviewed were able to corroborate the allegation: Resident developed a pressure injury while in care. Regarding the allegation: Facility did not notify resident's family of change in resident's medical condition the following was revealed: LPA Velazquez conducted interviews with the complainant, Resident (R) #2’s family, residents, and staff. LPA Velazquez also reviewed and obtained copies of pertinent documents. The records reviewed included medical records from Los Alamitos Medical Center including photographs taken in the Emergency Department of R2’s pressure injuries, PIH Hospice of Presbyterian hospice records, Physician’s Reports, Advanced Health Care Directive, Resident Appraisals, Preplacement Appraisal Information forms, and Admission Agreements. When interviewed two of two facility staff stated R2 had no pressure injuries prior to being sent out to the hospital. R2's facility documentation indicated R2 "no bed sores" which Administrator Catibog confirmed. R2's family first became aware of R2's pressure injuries in the Emergency Department when R2 was transported via ambulance to Los Alamitos Medical Center on September 22, 2022. Per Administrator Catibog an Unusual Incident/Injury Report (LIC 624) was not submitted to Community Care Licensing Division pursuant to statute and regulation regarding R2's hospitalization. Based on the observations of LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Resident developed a pressure injury while in care and Facility did not notify resident's family of change in resident's medical condition are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Runette Catibog and a copy of this report along with the appeal rights, LIC 811, and LIC 9098 were provided at the time of this visit.