Follow-up on corrections·January 19, 2024

On 1/19/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with designee, Shenel Phang . LPA spoke with Administrator by phone regarding the report and findings. On 12/14/23, LPA Mknelly, conducted a visit and issued a citation based on the information available at the facility at the time regarding an incident report received by the department on 12/12/23. The 12/12/23 incident report was regarding a hospital visit for R1 on 12/7/23. LPA conducted a records review regarding R1. Records found that R1 was admitted to this facility on 10/25/23. Discharge instructions from the referring hospital identified R1 as having wounds that require daily ongoing wound care. Between 10/25/23 and 12/7/23 R1 did not receive home heath wound care at the facility. Following the 12/14/23 visit, LPA Mknelly collected the following additional records regarding R1’s wounds care history: referring hospital wound care and discharge status of wounds, area hospital records for 12/7/23- 12-9/23, and current home health records. Referring hospital wound care records, received from the hospital by LPA on 1/11/24, showed that on 10/25/23, R1 was transferred to this facility with a stage IV Sacrococcygeal pressure injury, a Full thickness (non- pressure) injury to left thigh, contractures requiring continued physical therapy. Report continued... 10/25/23 discharge instructions recommended daily dressing changes to the Sacral and sacrococcygeal pressure injuries and dressing change to the left thigh wound every other day. An appointment for a tele-health follow-up call on 1/30/23. Licensee did not present a record that the 10/30/23 tele-health call occurred. R1’s LIC 602- physician’s report, dated 9/19/23, noted non-healing wounds. R1’s LIC 625- Appraisal Needs and Services Plan, dated 11/29/23, listed severe deformity and contractures requiring exercise. There was no wound care plan developed. On 12/7/23- 12/9/23 area hospital records noted: HISTORY OF PRESENT ILLNESS : (R1) brought in by ambulance sent to the emergency department by board and care facility for wound check. Patient reports (R1) is worried for infection as (R1) was just admitted into the hospital one month ago for chronic pressure wounds to his coccyx, elbows, and lower extremities. (R1) is concerned for infection and states the wound to his left lower extremity is more red and starting to become black. Emergency department diagnosis: Pressure ulcer of sacral region, unspecified stage; Pressure ulcer of left hip, unspecified stage; Pressure ulcer of right hip, unspecified stage and Abrasion of scalp, initial encounter. R! was admitted for wound care evaluation and for case management to discuss resources for discharge planning. On wound care evaluation patient was found to healing pressure ulcers to sacrum and bilateral hips as well as healing open wound to left anterior thigh unclear etiology as well as abrasion to posterior scalp again of unclear etiology. R1 returned to the facility on 12/9/24 with orders for Home Health which began on 12/10/24. Home health records showed that on 12/22/23 R1 was assessed to have two (2) stage III pressure injuries. One to the coccyx and to low right buttocks. (Note: the buttocks pressure injury was no noted at discharge from the referring hospital.) The injuries were explicitly identified to facility staff. Staff, Nerryrose Kreig , who was informed by Home Health, did not take immediate action to request and exception from licensing or to have R1 seen at a hospital until 1/2/23, at the prompting by LPA Mknelly, for this prohibited health condition. ER doctor determined that R1’s wounds were stage II or less and R1 returned to the facility with continued Home Health Wound care. Therefore, medical records review found that in addition to the citation issued on 12/14/23 for a lack of a wound care plan for R1, R1 was admitted and knowing retained at the facility with prohibited conditions of Stage III and IV pressure injuries. Those healing wounds were also neglected by facility staff between 10/25/23 and 12/7/23 which severely risked R1’s health and safety. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted. Report reviewed. Copy of report and appeal rights provided