Inspector’s narrative
What the inspector wrote
It was alleged that, due to lack of care and supervision by facility staff, R1, who is bedridden and wheelchair bound, sustained an unstageable wound on their tailbone at the facility. Per R1’s UCI Medical Records, on July 15, 2024, R1 was admitted to the hospital and diagnosed with a 2.5 centimeter by 2.5 centimeter unstageable bed sore on the tailbone which is black in appearance. Per R1’s Physician’s Report dated March 23, 2024, R1 has Dementia, is non-ambulatory and uses a wheelchair, and is incontinent. R1’s undated Appraisal/Needs and Services Plan indicates R1 is incontinent, uses diapers, and requires staff to change their diapers. Four staff described that R1 needs assistance with all activities of daily living and spends a majority of their time in bed. Based on this information, R1 was at risk for developing pressure injuries. Three staff stated that residents are repositioned and checked for skin conditions every two hours, as well as during clothing changes, diaper changes, and showers, but no body check logs are maintained and instead any issues are reported verbally to the medication technician. Staff #1 (S1), who changed R1 at least once during the overnight shift from 10:30PM on July 14, 2024, to 7:00AM on July 15, 2024, denied seeing any wounds on R1, but also denied that they were properly repositioning R1 because R1’s body is very rigid. Staff #2 (S2) stated they noticed a quarter-sized red wound on R1’s tailbone around July 8, 2024, they reported it to Staff #4 (S4), the facility’s medication technician, and they put cream on the wound but were unable to tell if the wound was improving. S4 claimed they first learned of R1’s wound on July 15, 2024, confirmed they are not qualified to provide wound care, and stated that when they learned of R1’s wound on July 15, 2024, they reported to Witness #1 (W1), a third-party nurse who was present at the time. W1 stated they have previously provided treatment for R1’s occasional rashes, on July 15, 2024, they were advised by S4 of R1’s wound, they were unable to assess the wound due to R1 having a separate injury which required transfer to the hospital, but they were able to place a bandage on the wound prior to R1 going to the hospital. R1’s Nurse Progress Notes, which date from May 18, 2024, through R1’s hospitalization on July 15, 2024, do not document that any wounds were noticed or treated. Based on the information obtained, facility staff were not properly repositioning R1 and did not obtain assessment or treatment for R1’s wound for a week after its discovery around July 8, 2024.
During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
It was alleged that, due to lack of care and supervision by facility staff, R1, who is bedridden and wheelchair bound, sustained a right femur fracture which required hospitalization. Per R1’s Physician’s Report dated March 23, 2024, R1 has Dementia, is non-ambulatory and uses a wheelchair, and leans forward while in a wheelchair which indicates that R1 is a fall risk. Four staff described that R1 needs assistance with all activities of daily living, spends a majority of their time in bed, cannot get out of bed or their wheelchair alone and does not attempt to do so, and requires two staff to transfer between their bed and wheelchair. Per Staff #1 (S1), on July 15, 2024, between 5:30AM and 6:00AM, they checked on R1, observed R1 moving around in bed, was starting to change R1 but heard a noise like a bone moving, did not observe any visible injuries, and reported the issue to Staff #2 (S2) and Staff #3 (S3) at shift change. S1 worked the overnight shift from 10:30PM on July 14, 2024, to 7:00AM on July 15, 2024, and had changed R1 previously during this same shift and did not notice any issues with R1. Per S2 and S3, on July 15, 2024, around 5:30AM, they went to R1’s room, saw R1 in bed, were advised by S1 that R1 was not acting normal, but noted that R1 was comfortable, eating breakfast, and not complaining of pain. S2 also provided a conflicting statement that they saw R1 on the floor and placed R1 back in bed, but later rescinded this statement. S2 and S3 had also worked on July 14, 2024, changed and bathed R1, and did not notice any issues with R1 on that day. Two additional staff provided statements that they observed no issues with R1 on July 14, 2024, and staff interviews and facility records did not reveal any reported falls for R1 relating to this injury. Staff #4 (S4), the facility’s medication technician, stated they were advised of the situation with R1 on the morning of July 15, 2024, they checked on R1 and noted R1’s upper right thigh was swollen, and they called an ambulance and requested an assessment from Witness #1 (W1), a third-party nurse who was present at the time. Per W1, after being advised of the issue with R1, they assessed R1, observed swelling on R1’s thigh but no redness or bruising, and noted R1 did not complain about pain. R1’s UCI Medical Records reveal that on July 15, 2024, R1 was diagnosed with a “displaced comminuted fracture of shaft of right femur”, which is a fracture in the large upper leg bone where the bone is in at least three pieces which are no longer in alignment, R1 underwent “R femur ORIF” on July 16, 2024, which is a surgery to realign and connect the broken pieces of bone using a plate and screws, and R1 was recommended for hospice. One of R1’s treating physicians provided a statement indicating they could not definitively say what caused R1’s fracture, it is highly likely it was caused by a rotational injury, but due to R1’s age and poor quality of bone structure, it is possible the fracture may have been caused when R1 moved or their leg was moved by another person to change them. The information obtained regarding what caused R1’s fracture is conflicting and did not corroborate the allegation.
Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
