complaint·February 26, 2025

Wound was described as wound location: left trochanter, type of wound: consistent with pressure related injury, stage was listed as unstageable and wound size was listed as 4.2 x 4 cm. The left trochanter is located at the top of the left thighbone, on the outside of the hip. Interviews with staff were conducted and 5 of 6 staff indicated they did not observe any pressure injuries on R1. The sixth staff did not reveal knowledge of any pressure injuries. During staff interviews, 4 of 6 revealed R1 would pick at their skin causing small wounds. Staff would then clean and bandage the wounds. It was not clear during interviews where the wounds were located on R1. Narrative Charting dated 02/19/2022 corroborated staff interviews. The Narrative Charting revealed care staff reported R1 is pinching their skin, causing small wounds, the wounds were cleaned and bandaged. R1 was not able to be interviewed. Based on interviews and records review the allegation of resident sustained an unstageable pressure injury while in care is unsubstantiated . A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. It was alleged that resident sustained injuries resulting in hospitalization due lack of care and supervision. R1 moved into the facility on 01/13/2022. R1’s Physicians Report dated 12/17/2021 indicated R1 was ambulatory. The Physician’s Report does not list R1 as a fall risk. R1’s AL Advantage Memory Care Resident Assessment was reviewed. The assessment is neither dated nor does it include R1’s name. However, the assessment was provided by the facility staff as relating to R1. The assessment indicates R1’s level of assistance as R1 was to receive (8) eight status checks per shift. Investigation did not reveal documentation of the eight (8) status checks per shift. Staff interviews revealed R1 was found on the floor. Staff interviews further indicated R1 was transported to the hospital on 02/08/2022 due to the un-witnessed fall. Medical records dated 02/08/2022 revealed R1 was noted with a contusion to the right elbow and the back of the right hand. R1 was discharged back to the facility on 02/09/2022. Narrative Charting dated 02/21/2022, revealed R1 was sent back to the hospital due to self-harm. Medical records dated 02/21/2022 revealed R1 had a chief complaint of agitation. Medical records for the 02/21/2022 hospital visit is where it was revealed an “anticipated” diagnosis of right hip fracture. Based on interviews and records review the allegation of resident sustained injuries resulting in hospitalization due lack of care and supervision is unsubstantiated . A finding that the complaint is unsubstantiated means Continued on LIC9099-C... It was alleged that staff did not meet the needs of resident in care. Resident (R1) moved into the facility on 01/14/2022, according to records obtained R1s Physicians report indicated R1 baseline is cognitive impairment, including screaming episodes, confusion, and hallucination. R1s physician report also revealed R1 was ambulatory and not listed as a fall risk. Facility staff made several observations of R1s exhibited behaviors consisting of screaming episodes, displaying confusion, and hallucinating. In addition, staff observed R1 throw themselves out of their wheelchair on a regular basis. On 2/8/2022 R1 was transported to the hospital and admitted for a fall, supportive documents revealed R1 was in their apartment sitting in a chair when they tried getting up and then fell. R1 sustained injuries from their fall, contusion to the right hand and elbow. R1 returned to the facility from the hospital on 2/9/2022, there were no new appraisals or assessments completed by the facility staff indicating a change in R1s condition. According to information obtained through staff interviews, the facility did not provide one-on-one service to any residents. Additionally, the facility had three (3) caregivers per shift for twenty-five (25) residents. The facility also had one (1) medical technician, who would fulfill caregiver duties after passing medications. Information obtained through interviews revealed the med-tech would move the resident closer to them (med-tech) whenever the med-tech had to attend to other residents who required their assistance. Based on interviews and records review R1 was not reassessed by the facility staff after experiencing a fall and being hospitalized, therefore the allegation staff did not meet the needs of resident in care is found to be substantiated. The preponderance of the evidence standard has been met; therefore, the above allegation is found to be substantiated . California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided. that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. It was alleged that staff did not notify responsible party of resident's change in condition. Information obtained through interviews revealed upon R1s admission to the facility, R1 was observed in their wheelchair covered with a blanket and a lap belt on them to secure them in the wheelchair to prevent them from falling. After R1’s admission, the facility staff removed the lap belt due to the lap belt being a form of restraint. According to staff’s observations R1 would then proceed to throw themselves out of the chair on a regular basis. R1 was provided with a recliner by R1s daughter however this was identified as another form of restraint. In addition, R1 began to exhibit behaviors, picking at their skin on a regular. Staff would treat R1s wound by cleaning and bandaging R1 each time R1 would pick at their skin. Evidence gathered during this investigation confirms the facility staff and R1s power of attorney (POA) were in constant communication via in-person visits, phone calls, and or text messages regarding R1s activities of daily living (ADL’s). Based on interviews and records review the allegation of staff did not notify responsible party of resident's change in condition is unsubstantiated . A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.