Inspector’s narrative
What the inspector wrote
According to interviews conducted, in August of 2022 R1 had a wound on their right foot due to bunions. Medical records indicated the wound was completely healed by the end of January 2023. R1 was admitted to Granite Bay CountryHouse on 2/1/2023, after recovering from bunion surgery. Granite Bay CountryHouse staff were aware of R1’s foot condition. Based on records review, R1’s podiatrist indicated staff were to monitor R1’s feet for any changes or worsening condition.
The Department subpoenaed R1’s medical records for review. According to medical records, R1 was transferred to local Emergency Department (ED) by ambulance on 10/09/2023. It was discovered that R1 had sustained two open wounds on the bottom of the right foot that measured two centimeters by three centimeters each. The wounds were malodorous and expressed salmon colored purulence when touched. On 10/10/2023, hospital staff admitted R1 to the Intensive Care Unit (ICU) due to the following: septic shock, altered mental status, acute respiratory failure with hypoxia, elevated troponin, acute kidney injury, and cellulitis of right leg. On 10/11/2023, R1 was seen and evaluated by hospital medical professionals. Medical records indicated medical staff determined R1 required a right Trans-metatarsal amputation (TMA) to prevent spread of infection and systemic illness. On 10/13/2023, due to septic shock, R1 underwent a right lower extremity angioplasty and a right TMA.
The Department requested for the facility to submit R1’s physician’s report, pre-placement appraisal, assessments, and plan of care for review. According to R1’s physician’s report dated 11/20/2022, R1’s primary diagnosis is Dementia without behavioral disturbance. The secondary diagnosis is right foot ulcer with wound care being ordered twice weekly. Preplacement appraisal notes R1 has a stint in the right leg and is non-ambulatory. R1’s initial assessment was conducted by the facility on 01/26/2023. According to the assessment conducted, nail care is to be provided by a Podiatrist every month as needed. Instructions included for staff to monitor for signs and symptoms (i.e., reddened areas on the toes, dark areas on toes, non-healing open areas, resident reports discomfort), any observations will be reported to the nurse. R1 is a stand-by assist during bathing, assist in/out of bath/shower, assist with washing back and assist with drying weekly.
According to interview with R1’s Podiatrist (W1), R1 was seen on three (3) separate occasions while residing at the facility. On 3/18/2023, W1 indicated R1 had red, swollen feet, and complained of pain in toes. W1 prescribed a change of shoe for R1 at that time. On 6/8/2023, R1 was seen again by W1, during this appointment R1’s foot was doing better. At the time of the appointment, it was noted there were no signs of redness, swelling, open wounds, and no complaint of pain. On 8/28/2023, W1 had final visit with R1 and noted there was no sign of any redness, swelling, open wounds, and there was no complaint of pain. W1 indicated that during R1’s appointment on 8/28/2023, R1’s foot was in good condition. During the interview with W1, it was mentioned R1’s 10/09/2023 hospital visit W1 expressed surprise as they stated the facility never contacted them regarding R1’s feet deterioration. W1 further stated, “
For an infection to get that bad there would be a lot of early warning signs such as pain, swelling, and discoloration. An infection would take time to become that severe and it should have been noticed by staff well before reaching that level”
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The Department conducted interviews and received statements from a total of seven (7) facility staff and five (5) residents in care. Interview statement received from staff (S1) indicated, R1 was admitted into the facility in February 2023. S1 stated, R1 had a “stand-by” assist for showers. During a stand-by assist, caregivers are supposed to help undress the resident, help the resident enter the shower, and help them dry off. During this time the staff are supposed to be looking for any concerns or issues while they are assisting the residents.
Interview statement received from S2 indicated, S2 worked at the facility from July 2023 to November 2023. S2 stated staff (S3) was the staff who worked with R1 and was responsible for bathing needs. S2 observed there were very few observation notes in R1’s ECP (computer program log). When S2 asked S3 about the lack of notes, S3 told S2 that R1 refused to be bathed every single time. The refusals were never logged in ECP which S3 never told anyone about R1 refusing care or never mentioned R1 having any other signs or symptoms of any kind. S2 stated did not have any knowledge of R1’s foot condition until after R1 was sent to the hospital. S2 was unfamiliar with R1’s medical history. S2 stated information regarding R1’s pre-existing foot issue was not available when S2 took over.
Interview statement received from former staff (S3) indicated, S3 worked at the facility from March 2023 through November 2023 as a caregiver and Med Tech. S3 stated information was passed down via word of mouth at shift change and via computer system used to enter notes (ECP). S3 notified management about the issues with ECP but the system was never fixed. S3 worked with R1 frequently and assisted R1 with showers. S3 stated R1 would often refused showers. S3 stated never saw any redness, swelling, or open wounds on R1’s body. S3 stated had knowledge of R1’s foot condition when S3 began working at the facility in March 2023. During S3’s interview, they admitted to not checking the condition of R1’s feet.
Based on interview statements and records review, staff did not observe and monitor R1 for signs and symptoms (i.e., reddened areas on the toes, dark areas on toes, non-healing open areas, resident reports discomfort) which resulted in R1 being admitted to the hospital for septic shock where R1 sustained a right lower extremity angioplasty and right Trans-metatarsal amputation.
The Department finds the allegation to be SUBSTANTIATED. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations, Title 22, is cited on the attached LIC 9099-D.
The facility is being advised that under H&S Code §1568 the issuance of a Civil Penalty is currently under review and may be assessed later, due to a resident sustaining serious bodily injury while in care of the facility.
Appeal rights provided.
Exit interview conducted. A copy of this report was left at the facility.
